Basic Information
| Provider Information | |||||||||
| NPI: | 1043441967 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES WASHINGTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3505 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255256778 | ||||||||
| FaxNumber: | 4255256700 | ||||||||
| Practice Location | |||||||||
| Address1: | 24070 NE STATE ROUTE 3 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BELFAIR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985289665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602770523 | ||||||||
| FaxNumber: | 3602752271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2009 | ||||||||
| LastUpdateDate: | 10/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REIMBURSEMENT ADMINISTRATI | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | N | Hospital Units | Rehabilitation, Substance Use Disorder Unit | 261QR0405X | 00000974 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 1993070 | 05 | WA | MEDICAID |