1104024348 NPI number — PROVIDENCE HEALTH & SERVICE WASHINGTON

Table of content: (NPI 1104024348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104024348 NPI number — PROVIDENCE HEALTH & SERVICE WASHINGTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICE WASHINGTON
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:
Provider Other Organization Name Type Code:
6
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:
1104024348
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34439
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-1439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-525-6778
Provider Business Mailing Address Fax Number:
425-525-6700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218-A MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98356-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-496-6216
Provider Business Practice Location Address Fax Number:
360-496-6232
Provider Enumeration Date:
07/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
QUINN
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PAYOR CREDENTIALING MANAGER
Authorized Official Telephone Number:
425-525-6715

Provider Taxonomy Codes

  • Taxonomy code: 103TA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 602 399 531 . This is a "UBI MASTER LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1250 . This is a "BUSINESS LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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