Basic Information
| Provider Information | |||||||||
| NPI: | 1568961969 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH OLYMPIC HEALTHCARE NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 W FRONT ST STE A | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983622609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604527891 | ||||||||
| FaxNumber: | 3604528087 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 W FRONT ST STE A | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604527891 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2018 | ||||||||
| LastUpdateDate: | 05/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | MAXWELL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3604527891 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH OLYMPIC HEALTHCARE NETWORK | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2046838 | 05 | WA | MEDICAID |