Basic Information
| Provider Information | |||||||||
| NPI: | 1609018076 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL PRACTICE MANAGEMENT, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PACIFIC CREST FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2947 | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989072947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092487849 | ||||||||
| FaxNumber: | 5092488291 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 S 72ND AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989081661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099721818 | ||||||||
| FaxNumber: | 5099727842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 04/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | SIMMONS | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5092487849 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 7091168 | 05 | WA | MEDICAID |