1760582522 NPI number — PACIFIC COUNTY HOSPITAL DISTRICT 2

Table of content: (NPI 1760582522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760582522 NPI number — PACIFIC COUNTY HOSPITAL DISTRICT 2

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC COUNTY HOSPITAL DISTRICT 2
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:
WILLAPA MEDICAL CLINIC
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:
1760582522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 269
Provider Second Line Business Mailing Address:
826 ALDER ST.
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98586-0269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-875-5579
Provider Business Mailing Address Fax Number:
360-875-5235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
826 ALDER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98586-4900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-875-5579
Provider Business Practice Location Address Fax Number:
360-875-5235
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCALLISTER
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC MANAGER
Authorized Official Telephone Number:
360-875-5579

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0317075 . This is a "LABOR & INDUSTRIES-DR. BUBEN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9621491 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0317062 . This is a "LABOR & INDUSTRIES-PFHC" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0317067 . This is a "LABOR & INDUSTRIES-JARED ABRAMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1035732 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GAB11482 . This is a "RENDERING PIN BUBEN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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