Basic Information
| Provider Information | |||||||||
| NPI: | 1659571362 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-CITIES COMMUNITY HEALTH | ||||||||
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| OtherOrganizationName: | BENTON FRANKLIN COUNTY DETOXIFICATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 S 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993015794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095472207 | ||||||||
| FaxNumber: | 5095428836 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 W COURT ST | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095456506 | ||||||||
| FaxNumber: | 5095460520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | CARDOZA | ||||||||
| AuthorizedOfficialFirstName: | MONICA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5095431920 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1995026 | 05 | WA | MEDICAID |