Basic Information
Provider Information | |||||||||
NPI: | 1962586503 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLINIC AT ROYAL CITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLINIC AT ROYAL CITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1028 | ||||||||
Address2: |   | ||||||||
City: | ROYAL CITY | ||||||||
State: | WA | ||||||||
PostalCode: | 993571028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 101 CAMELIA ST NW | ||||||||
Address2: |   | ||||||||
City: | ROYAL CITY | ||||||||
State: | WA | ||||||||
PostalCode: | 99357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093461447 | ||||||||
FaxNumber: | 5093461481 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHACKELFORD | ||||||||
AuthorizedOfficialFirstName: | DIRENDIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGED CARE SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 8006540889 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | MD00010548 | WA | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
ID Information
ID | Type | State | Issuer | Description | 8213605 | 05 | WA |   | MEDICAID | 4928137 | 01 |   | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |