Provider Demographics
NPI:1285607796
Name:CITY OF PUYALLUP
Entity type:Organization
Organization Name:CITY OF PUYALLUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-845-6666
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:360-394-7030
Mailing Address - Fax:360-394-7097
Practice Address - Street 1:902 7TH ST NW
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-4101
Practice Address - Country:US
Practice Address - Phone:253-845-6666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA27M093416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0161618OtherL&I AND CRIME VICTIMS
WA9052945Medicaid
WAPU1220OtherREGENCE
WA590015201OtherRAILROAD MEDICARE
WA0161618OtherL&I AND CRIME VICTIMS