Basic Information
| Provider Information | |||||||||
| NPI: | 1124266762 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OKANOGAN COUNTY PUBLIC HOSPITAL DISTRICT NO 4 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TONASKET FAMILY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 203 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | TONASKET | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988558803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094862151 | ||||||||
| FaxNumber: | 5094863116 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | TONASKET | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988558803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094862151 | ||||||||
| FaxNumber: | 5094863116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCREYNOLDS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5094863128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OKANOGAN COUNTY PUBLIC HOSPITAL DISTRICT NO 4 | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | H-107 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | H-107 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 7149701 | 05 | WA | MEDICAID |