1447203104 NPI number — MID-VALLEY COMMUNITY CLINIC, PLLC

Table of content: (NPI 1447203104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447203104 NPI number — MID-VALLEY COMMUNITY CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-VALLEY COMMUNITY CLINIC, PLLC
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:
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:
1447203104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 957
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNNYSIDE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98944-0957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-839-6822
Provider Business Mailing Address Fax Number:
509-839-5913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 S 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNNYSIDE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98944-2243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-839-6822
Provider Business Practice Location Address Fax Number:
509-839-5913
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALMA
Authorized Official First Name:
HARLAN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
509-839-6822

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  601689666 , 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: 8283707 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD00026187 . This is a "DR WRUNG STATE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MD00032042 . This is a "DR HALMA STATE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1052273 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: OP00000839 . This is a "DR. SWOFFORD STATE LICENS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8156861 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7075070 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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