=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457618704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AT YOUR HOME PRIMARY CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2012
-----------------------------------------------------
Last Update Date | 04/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3922 113TH AVE SE
-----------------------------------------------------
City | SNOHOMISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98290-5589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-299-2170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 126
-----------------------------------------------------
City | SNOHOMISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98291-0126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-299-2170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. KIMBERLY RUTH POPPE
-----------------------------------------------------
Credential | ARNP
-----------------------------------------------------
Telephone | 425-299-2170
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------