Basic Information
| Provider Information | |||||||||
| NPI: | 1881135499 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEWIS COUNTY COMMUNITY HEALTH SERVICES | ||||||||
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| OtherOrganizationName: | VALLEY VIEW HEALTH CENTER - TENINO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2690 NE KRESKY AVE | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603309595 | ||||||||
| FaxNumber: | 3603309560 | ||||||||
| Practice Location | |||||||||
| Address1: | 273 SUSSEX AVE E | ||||||||
| Address2: | |||||||||
| City: | TENINO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985899359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602645665 | ||||||||
| FaxNumber: | 3602645666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2017 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3603309595 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 602312048 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | G8801670 | 01 | WA | MEDICARE PART B | OTHER | 7126972 | 05 | WA | MEDICAID |