Basic Information
Provider Information | |||||||||
NPI: | 1528316379 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLUMBIA BASIN HEALTH ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EAGLE EYE CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1515 E COLUMBIA ST | ||||||||
Address2: |   | ||||||||
City: | OTHELLO | ||||||||
State: | WA | ||||||||
PostalCode: | 993441846 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094885256 | ||||||||
FaxNumber: | 5094889939 | ||||||||
Practice Location | |||||||||
Address1: | 1051 S. COLUMBIA AVENUE | ||||||||
Address2: |   | ||||||||
City: | CONNELL | ||||||||
State: | WA | ||||||||
PostalCode: | 99326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094885256 | ||||||||
FaxNumber: | 5094889939 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2012 | ||||||||
LastUpdateDate: | 05/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOMEZ | ||||||||
AuthorizedOfficialFirstName: | NIEVES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5094885256 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | WA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 7107675 | 01 | WA | UGS MDC DSHS CROSSOVER | OTHER | CO3323 | 01 | WA | RAILROAD MEDICARE | OTHER | 8908941 | 01 | WA | DLI CRIME VICTIMS# | OTHER | 0035900 | 01 | WA | DLI GROUP# | OTHER |