1760636690 NPI number — PROVIDENCE HEALTH & SERVICES - WASHINGTON

Table of content: (NPI 1760636690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760636690 NPI number — PROVIDENCE HEALTH & SERVICES - WASHINGTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICES - WASHINGTON
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:
1760636690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31001-4114
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91110-4114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W POPLAR ST STE 50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-522-1030
Provider Business Practice Location Address Fax Number:
509-526-8402
Provider Enumeration Date:
11/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
ASSISTANT SECRETARY OF ENROLLMENTS
Authorized Official Telephone Number:
425-358-9786

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  H-050 , 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)





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