Healthcare Provider Details

I. General information

NPI: 1821053208
Provider Name (Legal Business Name): MAIN STREET HEALTH ASSOCIATES, P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 12/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 WEST MAIN AVENUE
BREWSTER WA
98812
US

IV. Provider business mailing address

PO BOX 40
BREWSTER WA
98812-0040
US

V. Phone/Fax

Practice location:
  • Phone: 509-689-8900
  • Fax: 509-689-9031
Mailing address:
  • Phone: 509-689-8900
  • Fax: 509-689-9031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number601803678
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number601803678
License Number StateWA

VIII. Authorized Official

Name: LINDA NIEHAUS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 509-689-8900