Healthcare Provider Details

I. General information

NPI: 1205104593
Provider Name (Legal Business Name): PULLMAN REGIONAL HOSPITAL CLINIC NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 S BLAINE ST STE 5
MOSCOW ID
83843-3973
US

IV. Provider business mailing address

840 SE BISHOP BLVD STE 101
PULLMAN WA
99163-5502
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-2247
  • Fax: 509-336-7482
Mailing address:
  • Phone: 509-332-6139
  • Fax: 509-332-6579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number13-3860
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: GROVER 'PETE' C PETERS III
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 509-332-6139