Basic Information
| Provider Information | |||||||||
| NPI: | 1063611408 | ||||||||
| 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: | 4255256717 | ||||||||
| FaxNumber: | 4255256700 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 GOLF CLUB RD SE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985031048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604937469 | ||||||||
| FaxNumber: | 3604592023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| 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 | 261Q00000X | H-159 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 8919875 | 01 | WA | L&I CRIME VICTIMS | OTHER | 129210 | 01 | WA | L&I | OTHER | 7115611 | 05 | WA | MEDICAID |