1417148461 NPI number — PROVIDENCE HEALTHCARE

Table of content: (NPI 1417148461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417148461 NPI number — PROVIDENCE HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTHCARE
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:
DEER PARK HOSPITAL CRNA
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:
1417148461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 N WASHINGTON ST
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99201-2202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-276-5061
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 E D ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEER PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99006-5067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-232-1173
Provider Business Practice Location Address Fax Number:
509-232-1165
Provider Enumeration Date:
08/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WICKLUND
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
509-232-1177

Provider Taxonomy Codes

  • Taxonomy code: 282NR1301X , with the licence number:  H 178 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000015 . This is a "FACILITY ID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: H 178 . This is a "LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9043233 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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