Basic Information
| Provider Information | |||||||||
| NPI: | 1003987868 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-CITIES DIGESTIVE HEALTH CENTER, PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8819 W VICTORIA AVE | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094605500 | ||||||||
| FaxNumber: | 5094605111 | ||||||||
| Practice Location | |||||||||
| Address1: | 8819 W VICTORIA AVE | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094605500 | ||||||||
| FaxNumber: | 5094605111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 11/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | BOONPONGMANEE | ||||||||
| AuthorizedOfficialFirstName: | CHAYANIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5094605500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 7109432 | 05 | WA | MEDICAID |