Provider Demographics
NPI: | 1518157320 |
---|---|
Name: | ALPHA ADVANTAGE |
Entity Type: | Organization |
Organization Name: | ALPHA ADVANTAGE |
Other - Org Name: | MARWILSON |
Other - Org Type: | Former Legal Business Name |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | JERETHA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MARBURY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 253-284-3255 |
Mailing Address - Street 1: | 1119 PACIFIC AVE FL 5 |
Mailing Address - Street 2: | |
Mailing Address - City: | TACOMA |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98402-4374 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 253-284-3262 |
Mailing Address - Fax: | 253-627-8783 |
Practice Address - Street 1: | 1119 PACIFIC AVE FL 5 |
Practice Address - Street 2: | |
Practice Address - City: | TACOMA |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98402-4374 |
Practice Address - Country: | US |
Practice Address - Phone: | 253-284-3262 |
Practice Address - Fax: | 253-627-8783 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-07-27 |
Last Update Date: | 2007-07-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | 332B00000X | 332B00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |