Basic Information
| Provider Information | |||||||||
| NPI: | 1316934110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE MOUNTAIN GENETICS CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 W WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095251302 | ||||||||
| FaxNumber: | 5095229448 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 W WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095251302 | ||||||||
| FaxNumber: | 5095229448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5095251302 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Genetic Counselor, MS |
ID Information
| ID | Type | State | Issuer | Description | 7110661 | 05 | WA | MEDICAID |