Basic Information
| Provider Information | |||||||||
| NPI: | 1528025293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENINSULA CHILDRENS CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 902 E CAROLINE | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604578578 | ||||||||
| FaxNumber: | 3604574841 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 E CAROLINE | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604578578 | ||||||||
| FaxNumber: | 3604574841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WELLER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | PEDIATRICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3604578578 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 601481297 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 7058894 | 01 | WA | DSHS | OTHER |