Basic Information
| Provider Information | |||||||||
| NPI: | 1053539890 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA BASIN HEALTH ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WAHLUKE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1515 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 GOVERNMENT WAY | ||||||||
| Address2: | |||||||||
| City: | MATTAWA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099323535 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPURRIER | ||||||||
| AuthorizedOfficialFirstName: | JANINE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5094885256 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 7407927 | 05 | WA | MEDICAID | 0135012 | 01 | WA | DEPT OF L&I | OTHER | 50D9963406 | 01 | WA | CLIA # | OTHER | 7107675 | 01 | WA | UGS MDC DSHS CROSSOVER | OTHER | 8908941 | 01 | WA | CRIME VICTIMS # | OTHER | 7096555 | 05 | WA | MEDICAID | 7900624 | 01 | WA | TAKE CHARGE # | OTHER |