Basic Information
| Provider Information | |||||||||
| NPI: | 1750465365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BEND CLINIC DBA RIVERVIEW HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 666 | ||||||||
| Address2: | |||||||||
| City: | RAYMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985770666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609423040 | ||||||||
| FaxNumber: | 3609423955 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 OCEAN AVE | ||||||||
| Address2: | |||||||||
| City: | RAYMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985773016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609423040 | ||||||||
| FaxNumber: | 3609423955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | VAIL-LUSH | ||||||||
| AuthorizedOfficialFirstName: | RHONDI | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER/CORPORATE SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 3609424562 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OP00000626 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7840408 | 05 | WA | MEDICAID | 7086515 | 05 | WA | MEDICAID |