Healthcare Provider Details

I. General information

NPI: 1952603532
Provider Name (Legal Business Name): RED MOUNTAIN FIELD CASE MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51621 DEMOSS RD
BENTON CITY WA
99320
US

IV. Provider business mailing address

51621 DEMOSS RD
BENTON CITY WA
99320
US

V. Phone/Fax

Practice location:
  • Phone: 509-851-8707
  • Fax: 509-588-3532
Mailing address:
  • Phone: 509-851-8707
  • Fax: 509-588-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number00090060
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberRN00110622
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number00090060
License Number StateWA

VIII. Authorized Official

Name: SHAWN M. TABER
Title or Position: PRESIDENT/RN CERTIFIED CASE MANAGER
Credential: RN, CCM
Phone: 509-851-8707