Basic Information
| Provider Information | |||||||||
| NPI: | 1689805509 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES WASHINGTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3505 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255256778 | ||||||||
| FaxNumber: | 4255256700 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 COLLEGE ST SE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985034389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604567575 | ||||||||
| FaxNumber: | 3604935088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2009 | ||||||||
| LastUpdateDate: | 10/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REIMBURSEMENT ADMINISTRATI | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | N | Hospital Units | Rehabilitation, Substance Use Disorder Unit | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 50-0143 | 01 | MEDICARE ID UNSPECIFIED | OTHER | 3400017 | 05 | WA | MEDICAID |