=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598013385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COPPER CREEK MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2012
-----------------------------------------------------
Last Update Date | 08/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 732 LEBO BLVD
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98310-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-792-2695
-----------------------------------------------------
Fax | 360-792-2697
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21222 30TH DR SE SUITE 210
-----------------------------------------------------
City | BOTHELL
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98021-7019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-621-1982
-----------------------------------------------------
Fax | 425-820-0831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ALFRED TALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-998-4309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------