1659558476 NPI number — PROVIDENCE HEALTH CARE

Table of content: (NPI 1659558476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659558476 NPI number — PROVIDENCE HEALTH CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH CARE
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:
1659558476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 W 5TH AVE
Provider Second Line Business Mailing Address:
STE 380
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99204-2966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-456-0262
Provider Business Mailing Address Fax Number:
509-624-8049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 W 7TH AVE
Provider Second Line Business Practice Location Address:
STE 330
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204-2349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-456-0262
Provider Business Practice Location Address Fax Number:
509-462-5059
Provider Enumeration Date:
01/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WALSTROM
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
509-474-3040

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  600503828 , 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: 7294903 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8870848 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: DG9549 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1370069 . This is a "MEDICARE PTAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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