Basic Information
Provider Information | |||||||||
NPI: | 1477163160 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLUMBIA VALLEY COMMUNITY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CVCH BEHAVIORAL HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 ORONDO AVE STE 1 | ||||||||
Address2: |   | ||||||||
City: | WENATCHEE | ||||||||
State: | WA | ||||||||
PostalCode: | 988012800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096626000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 504 ORONDO AVE STE A | ||||||||
Address2: |   | ||||||||
City: | WENATCHEE | ||||||||
State: | WA | ||||||||
PostalCode: | 988012830 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096621269 | ||||||||
FaxNumber: | 5096641037 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2020 | ||||||||
LastUpdateDate: | 08/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OLSON | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5096643528 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | 601108231 | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.