1790703106 NPI number — COUNTRY CLINIC

Table of content: (NPI 1790703106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790703106 NPI number — COUNTRY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY CLINIC
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:
1790703106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 945
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTHROP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98862-0945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-996-8180
Provider Business Mailing Address Fax Number:
509-996-3374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1116 HWY 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTHROP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-996-8180
Provider Business Practice Location Address Fax Number:
509-996-3374
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIAMOND
Authorized Official First Name:
ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN PARTNER
Authorized Official Telephone Number:
509-996-8180

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD00033304 , 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: 7103807 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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