Basic Information
Provider Information | |||||||||
NPI: | 1992859078 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OUR LADY OF LOURDES AT PASCO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LOURDES WILSON HOUSE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 224 N 7TH AVE | ||||||||
Address2: |   | ||||||||
City: | PASCO | ||||||||
State: | WA | ||||||||
PostalCode: | 993015411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095453390 | ||||||||
FaxNumber: | 5095432488 | ||||||||
Practice Location | |||||||||
Address1: | 224 N 7TH AVE | ||||||||
Address2: |   | ||||||||
City: | PASCO | ||||||||
State: | WA | ||||||||
PostalCode: | 993015411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095453390 | ||||||||
FaxNumber: | 5095432488 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SERLE | ||||||||
AuthorizedOfficialFirstName: | FOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 5095432483 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X |   | WA | Y |   | Agencies | Day Training, Developmentally Disabled Services |   |
No ID Information.