Provider Demographics
NPI:1215903778
Name:CITY OF MOUNTLAKE TERRACE
Entity type:Organization
Organization Name:CITY OF MOUNTLAKE TERRACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-551-1200
Mailing Address - Street 1:PO BOX 3510
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-3510
Mailing Address - Country:US
Mailing Address - Phone:360-613-1627
Mailing Address - Fax:360-698-4968
Practice Address - Street 1:12310 MERIDIAN AVE S
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5764
Practice Address - Country:US
Practice Address - Phone:425-551-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA31M103416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9046400Medicaid
WA126918OtherLABOR & INDUSTRIES
WA8923187OtherCRIME VICTIMS
WAMO3655OtherREGENCE
WAMO3655OtherREGENCE