Basic Information
| Provider Information | |||||||||
| NPI: | 1487870424 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHELAN COUNTY PUBLIC HOSPITAL DIST# 2 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAKE CHELAN COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 E HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHELAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988168631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096828517 | ||||||||
| FaxNumber: | 5096826131 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 E HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHELAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988168631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096828517 | ||||||||
| FaxNumber: | 5096826131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DION | ||||||||
| AuthorizedOfficialFirstName: | JERRI | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5096828517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | H-165 | WA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 3302304 | 05 | WA | MEDICAID |