Basic Information
| Provider Information | |||||||||
| NPI: | 1639812589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA COMMUNITY HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960 | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983370212 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 26201 SIYAYA AVE NE RM 121 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983469367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603773776 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2022 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | EMERY | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3603773776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENINSULA COMMUNITY HEALTH SERVICES | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 133N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 251B00000X | N | Agencies | Case Management | 251E00000X | N | Agencies | Home Health | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.