1255401683 NPI number — GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

Table of content: (NPI 1255401683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255401683 NPI number — GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
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:
DBA-MCCLEARY HEALTHCARE 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:
1255401683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 E. MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-346-2222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 W SIMPSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCLEARY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98557-9657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-346-2222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JENSEN
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
360-346-2222

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: HAC.FS.00000186 , 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: 7105406 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 106276 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 135 . This is a "REGENCE PRO" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 106275 . This is a "CRIME VICTIM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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