Healthcare Provider Details

I. General information

NPI: 1780320465
Provider Name (Legal Business Name): PENINSULA COMMUNITY HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 6TH ST RM STD BY ME
BREMERTON WA
98337-1441
US

IV. Provider business mailing address

PO BOX 960
BREMERTON WA
98337-0212
US

V. Phone/Fax

Practice location:
  • Phone: 360-377-3776
  • Fax:
Mailing address:
  • Phone: 360-377-3776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JOEL EMERY
Title or Position: CFO
Credential:
Phone: 360-475-6710