1376578773 NPI number — HOLLAND HEALTH SERVICES, INC

Table of content: (NPI 1376578773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376578773 NPI number — HOLLAND HEALTH SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLAND HEALTH SERVICES, INC
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:
1376578773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1406
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98273-1406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-424-7829
Provider Business Mailing Address Fax Number:
360-424-9053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1911 E DIVISION ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98274-6703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-424-7829
Provider Business Practice Location Address Fax Number:
360-424-9053
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLINS
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
360-424-7829

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9029927 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3580HO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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