Basic Information
| Provider Information | |||||||||
| NPI: | 1316034580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVID C WYNECOOP MEMORIAL CLINIC DHHS IHS WELLPINIT SERVICE UNIT | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WELLPINIT INDIAN HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6203 AGENCY LOOP ROAD | ||||||||
| Address2: | PO BOX 357 | ||||||||
| City: | WELLPINIT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990400357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092584517 | ||||||||
| FaxNumber: | 5092587152 | ||||||||
| Practice Location | |||||||||
| Address1: | 6203 AGENCY LOOP RD | ||||||||
| Address2: | |||||||||
| City: | WELLPINIT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990400357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092584517 | ||||||||
| FaxNumber: | 5092587152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILES | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5092584517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 6021166 | 05 | WA | MEDICAID | 4926309 | 01 | WA | PHARMACY NCPDP NUMBER | OTHER | 7100407 | 05 | WA | MEDICAID |