1386690907 NPI number — TRI-STATE MEMORIAL HOSPITAL

Table of content: (NPI 1386690907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386690907 NPI number — TRI-STATE MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE MEMORIAL HOSPITAL
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:
1386690907
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1221 HIGHLAND AVE.
Provider Second Line Business Mailing Address:
PO BOX 189
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-758-5511
Provider Business Mailing Address Fax Number:
509-751-9406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
730 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-3323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-8280
Provider Business Practice Location Address Fax Number:
208-746-8285
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TOWN
Authorized Official First Name:
ALEX
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
509-758-4667

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QE0700X , with the licence number: H-108 , 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: 003110900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3308004 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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