Basic Information
Provider Information | |||||||||
NPI: | 1336531888 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRO CARE MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTH MED CENTERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205 STEWART RD | ||||||||
Address2: | SUITE 104 | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982739607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604163322 | ||||||||
FaxNumber: | 3607077103 | ||||||||
Practice Location | |||||||||
Address1: | 205 STEWART RD | ||||||||
Address2: | SUITE 104 | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982739607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604163322 | ||||||||
FaxNumber: | 3607077103 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2015 | ||||||||
LastUpdateDate: | 02/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ECHEVARRIA | ||||||||
AuthorizedOfficialFirstName: | ELIANA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3604163322 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | AP60118940 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.