Basic Information
Provider Information | |||||||||
NPI: | 1679665483 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PENINSULA COMMUNITY HEALTH SERVICESS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 960 | ||||||||
Address2: |   | ||||||||
City: | BREMERTON | ||||||||
State: | WA | ||||||||
PostalCode: | 983370212 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604782366 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 320 S KITSAP BLVD | ||||||||
Address2: |   | ||||||||
City: | PORT ORCHARD | ||||||||
State: | WA | ||||||||
PostalCode: | 98366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608767215 | ||||||||
FaxNumber: | 3608955654 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2006 | ||||||||
LastUpdateDate: | 06/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KREIDLER-MOSS | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3604782366 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | CF00058729 | WA | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.