Healthcare Provider Details

I. General information

NPI: 1982708699
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 E REZANOF DR
KODIAK AK
99615-6602
US

IV. Provider business mailing address

PO BOX 3706
PORTLAND OR
97208-3706
US

V. Phone/Fax

Practice location:
  • Phone: 907-486-3281
  • Fax: 907-486-9546
Mailing address:
  • Phone: 907-486-3281
  • Fax: 907-486-9546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number309115
License Number StateAK

VIII. Authorized Official

Name: DONALD W ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786