Basic Information
| Provider Information | |||||||||
| NPI: | 1235759879 | ||||||||
| EntityType: | 2 | ||||||||
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| 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: | 4841 AUTO CENTER WAY STE 203 | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983124388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603773776 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2020 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEWALT | ||||||||
| AuthorizedOfficialFirstName: | JA-ANGEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST LEAD | ||||||||
| AuthorizedOfficialTelephone: | 3603773776 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 163WA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.