Basic Information
| Provider Information | |||||||||
| NPI: | 1568575504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELKHORN VALLEY CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY HEALTH CARE OF ELLENSBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 E MOUNTAIN VIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ELLENSBURG | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989265312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099626348 | ||||||||
| FaxNumber: | 5099622003 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 E MOUNTAIN VIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ELLENSBURG | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989265312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099626348 | ||||||||
| FaxNumber: | 5099622003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HANEY | ||||||||
| AuthorizedOfficialFirstName: | BYRON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5099626348 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4582 | 01 | WA | GROUP HEALTH | OTHER | 33120 | 01 | WA | LABOR & INDUSTRIES | OTHER | 7047830 | 05 | WA | MEDICAID |