Basic Information
| Provider Information | |||||||||
| NPI: | 1063521862 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALLA WALLA CLINIC, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALLA WALLA CLINIC MILTON-FREEWATER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 W TIETAN ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253720 | ||||||||
| FaxNumber: | 5095221592 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 NE 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | MILTON FREEWATER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978621702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419383314 | ||||||||
| FaxNumber: | 5419384449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 12/18/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | MICHELSON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5095253720 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WALLA WALLA CLINIC, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.