Basic Information
Provider Information | |||||||||
NPI: | 1215588371 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRI-CITIES COMMUNITY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1452 | ||||||||
Address2: |   | ||||||||
City: | PASCO | ||||||||
State: | WA | ||||||||
PostalCode: | 993011223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095472204 | ||||||||
FaxNumber: | 5095479329 | ||||||||
Practice Location | |||||||||
Address1: | 715 W COURT ST | ||||||||
Address2: |   | ||||||||
City: | PASCO | ||||||||
State: | WA | ||||||||
PostalCode: | 993014153 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095472204 | ||||||||
FaxNumber: | 5095479329 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2019 | ||||||||
LastUpdateDate: | 09/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5095431900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QC1500X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QD0000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.