Basic Information
| Provider Information | |||||||||
| NPI: | 1093006447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUR LADY OF LOURDES HEALTH CENTER | ||||||||
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| OtherOrganizationName: | LOURDES 14TH AVENUE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N 14TH AVE | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993014182 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 1200 N 14TH AVE | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993014182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095477704 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | SERLE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5095432483 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.