1821240425 NPI number — PROVIDENCE HEALTH & SERVICES - WA

Table of content: (NPI 1821240425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821240425 NPI number — PROVIDENCE HEALTH & SERVICES - WA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICES - WA
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:
PROVIDENCE ADULT DAY HEALTH
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:
1821240425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6018 N ASTOR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99208-1107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-482-2475
Provider Business Mailing Address Fax Number:
509-482-2490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6018 N ASTOR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99208-1107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-482-2475
Provider Business Practice Location Address Fax Number:
509-482-2490
Provider Enumeration Date:
10/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
ASSISTANT SECRETARY OF ENROLLMENT
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1027809 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 425223 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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