1790021822 NPI number — NORTH CENTRAL WASHINGTON HEALTH LLC

Table of content: (NPI 1790021822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790021822 NPI number — NORTH CENTRAL WASHINGTON HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH CENTRAL WASHINGTON HEALTH LLC
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:
MANSFIELD FAMILY MEDICINE
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:
1790021822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1050
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOAP LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98851-1050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-888-9606
Provider Business Mailing Address Fax Number:
509-246-8001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 WEST HIGHWAY 28
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOAP LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-888-9606
Provider Business Practice Location Address Fax Number:
509-246-8001
Provider Enumeration Date:
12/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LEINWEBER
Authorized Official First Name:
ELDON
Authorized Official Middle Name:
LESTER
Authorized Official Title or Position:
CEO, MANAGER
Authorized Official Telephone Number:
509-881-7503

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  PA10004217 , 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: 8418451 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q59925 . This is a "UPIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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