Basic Information
| Provider Information | |||||||||
| NPI: | 1508000142 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES - WASHINGTON | ||||||||
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| OtherOrganizationName: | PROVIDENCE SMMC URGENT CARE DME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 W POPLAR ST | ||||||||
| Address2: | PO BOX 1477 | ||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225906 | ||||||||
| FaxNumber: | 5095225789 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 CHASE AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225171 | ||||||||
| FaxNumber: | 5095225899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2009 | ||||||||
| LastUpdateDate: | 04/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | COLUMBER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 50952259096 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | HAC.FS.00000050 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.