Basic Information
| Provider Information | |||||||||
| NPI: | 1053562876 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES - WASHINGTON | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROVIDENCE ST MARY DME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1477 | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993620312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225906 | ||||||||
| FaxNumber: | 5095225789 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 CHASE AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225900 | ||||||||
| FaxNumber: | 5095225578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 06/12/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLUMBER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIR OF REVENUE CYCLE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 5095225906 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | H-050 | WA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 008478 | 01 | WA | L&I STATE | OTHER | 9055955 | 05 | WA | MEDICAID |