1760715106 NPI number — MID-COLUMBIA FAMILY PHYSICIANS,P.S.

Table of content: (NPI 1760715106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760715106 NPI number — MID-COLUMBIA FAMILY PHYSICIANS,P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-COLUMBIA FAMILY PHYSICIANS,P.S.
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:
MID COLUMBIA FAMILY HEALTH CENTER
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:
1760715106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1519
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE SALMON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98672-1519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-493-2133
Provider Business Mailing Address Fax Number:
509-493-9538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
875 SW ROCK CREEK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEVENSON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98648-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-427-4212
Provider Business Practice Location Address Fax Number:
509-427-4955
Provider Enumeration Date:
09/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LABERGE
Authorized Official First Name:
R
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
509-493-2133

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  600416746 , 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: 7033376 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com