Basic Information
| Provider Information | |||||||||
| NPI: | 1104590504 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENINSULA COMMUNITY HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960 | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983370212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603773776 | ||||||||
| FaxNumber: | 3603732096 | ||||||||
| Practice Location | |||||||||
| Address1: | 11901 137TH AVE NW UNIT A | ||||||||
| Address2: | |||||||||
| City: | GIG HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983296617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603773776 | ||||||||
| FaxNumber: | 3603732096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2021 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | NEAONVER | ||||||||
| AuthorizedOfficialFirstName: | MARIBEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3606163138 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.