Provider Demographics
NPI:1780206409
Name:WIMPRESS, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WIMPRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-1165
Mailing Address - Country:US
Mailing Address - Phone:541-272-9469
Mailing Address - Fax:
Practice Address - Street 1:1707 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9071
Practice Address - Country:US
Practice Address - Phone:360-523-8762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist