Basic Information
| Provider Information | |||||||||
| NPI: | 1427001940 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YAKIMA VALLEY FARM WORKERS CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIRASOL FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989480190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415671717 | ||||||||
| FaxNumber: | 5415645994 | ||||||||
| Practice Location | |||||||||
| Address1: | 589 NW 11TH ST | ||||||||
| Address2: | |||||||||
| City: | HERMISTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415671717 | ||||||||
| FaxNumber: | 5415645994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING VP | ||||||||
| AuthorizedOfficialTelephone: | 5098656175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | YAKIMA VALLEY FARM WORKERS CLINIC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 7087323 | 05 | WA | MEDICAID | 022793 | 05 | OR | MEDICAID | CD9420 | 01 | OR | RAILROAD MEDICARE | OTHER |