Provider Demographics
NPI:1467528976
Name:NORDLIE ENTERPRISES, INC.
Entity Type:Organization
Organization Name:NORDLIE ENTERPRISES, INC.
Other - Org Name:PREMIER MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:NORDLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-453-0555
Mailing Address - Street 1:555 116TH AVE NE
Mailing Address - Street 2:SUITE #180
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-5232
Mailing Address - Country:US
Mailing Address - Phone:425-453-0555
Mailing Address - Fax:425-453-6610
Practice Address - Street 1:555 116TH AVE NE
Practice Address - Street 2:SUITE #180
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5232
Practice Address - Country:US
Practice Address - Phone:425-453-0555
Practice Address - Fax:425-453-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601254898332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9058355Medicaid
WA9058355Medicaid