Basic Information
| Provider Information | |||||||||
| NPI: | 1659809457 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHC MEDICAL CENTER - TOPPENISH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VINTAGE VALLEY FAMILY MED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 719 | ||||||||
| Address2: | |||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989440719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098371617 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 915 VINTAGE VALLEY PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | ZILLAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989539800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098295151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2017 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | OWENS | ||||||||
| AuthorizedOfficialFirstName: | MAXWELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 5098371379 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 600581630 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.