Basic Information
| Provider Information | |||||||||
| NPI: | 1972517704 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YAKIMA VALLEY PROFESSIONAL SERVICES ON TIETON, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SELAH FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2947 | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989072947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092487849 | ||||||||
| FaxNumber: | 5092495042 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 W NACHES AVE | ||||||||
| Address2: | |||||||||
| City: | SELAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989421326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096975511 | ||||||||
| FaxNumber: | 5096979313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 12/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | SIMMONS | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5092487849 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.