Basic Information
| Provider Information | |||||||||
| NPI: | 1295288819 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOURDES HEALTH NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 207 CANYON DR | ||||||||
| Address2: | |||||||||
| City: | PROSSER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993501009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093038422 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1175 CARONDELET DR | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993543300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099439104 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2016 | ||||||||
| LastUpdateDate: | 08/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MNEDEZ | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENTIAL SERVICES CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5093038422 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASCENSION HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 602-813-810 | WA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.