1568575504 NPI number — ELKHORN VALLEY CORPORATION

Table of content: (NPI 1568575504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568575504 NPI number — ELKHORN VALLEY CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELKHORN VALLEY CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY HEALTH CARE OF ELLENSBURG
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568575504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 E MOUNTAIN VIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLENSBURG
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98926-5312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-962-6348
Provider Business Mailing Address Fax Number:
509-962-2003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 E MOUNTAIN VIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLENSBURG
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98926-5312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-962-6348
Provider Business Practice Location Address Fax Number:
509-962-2003
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANEY
Authorized Official First Name:
BYRON
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
509-962-6348

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4582 . This is a "GROUP HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 33120 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7047830 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com