Healthcare Provider Details

I. General information

NPI: 1063521862
Provider Name (Legal Business Name): WALLA WALLA CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 12/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 NE 5TH AVE
MILTON FREEWATER OR
97862-1702
US

IV. Provider business mailing address

55 W TIETAN ST
WALLA WALLA WA
99362-4445
US

V. Phone/Fax

Practice location:
  • Phone: 541-938-3314
  • Fax: 541-938-4449
Mailing address:
  • Phone: 509-525-3720
  • Fax: 509-522-1592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN MICHELSON
Title or Position: CEO
Credential:
Phone: 509-525-3720