1063521862 NPI number — WALLA WALLA CLINIC, INC.

Table of content: (NPI 1063521862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063521862 NPI number — WALLA WALLA CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLA WALLA CLINIC, INC.
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:
WALLA WALLA CLINIC MILTON-FREEWATER
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:
1063521862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 W TIETAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362-4445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-525-3720
Provider Business Mailing Address Fax Number:
509-522-1592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 NE 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON FREEWATER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97862-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-938-3314
Provider Business Practice Location Address Fax Number:
541-938-4449
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MICHELSON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
509-525-3720

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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