Basic Information
| Provider Information | |||||||||
| NPI: | 1003029745 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT CLARE HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PACLAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2670 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992202670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007528994 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11315 BRIDGEPORT WAY SE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007528994 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 04/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5097558700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 7079023 | 05 | WA | MEDICAID |