Healthcare Provider Details

I. General information

NPI: 1598141731
Provider Name (Legal Business Name): JDR CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7202 EVERGREEN WAY
EVERETT WA
98203-5661
US

IV. Provider business mailing address

7202 EVERGREEN WAY
EVERETT WA
98203-5661
US

V. Phone/Fax

Practice location:
  • Phone: 425-353-6563
  • Fax: 425-355-6159
Mailing address:
  • Phone: 425-353-6563
  • Fax: 425-355-6159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. LAWRENCE DALE RICHARDSON
Title or Position: OWNER
Credential: MBA
Phone: 425-353-6563