Healthcare Provider Details

I. General information

NPI: 1801266481
Provider Name (Legal Business Name): COWLITZ FAMILY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 1ST AVE SW
CASTLE ROCK WA
98611
US

IV. Provider business mailing address

1057 12TH AVE
LONGVIEW WA
98632-2509
US

V. Phone/Fax

Practice location:
  • Phone: 360-274-2353
  • Fax: 360-274-7439
Mailing address:
  • Phone: 360-636-3892
  • Fax: 360-232-8400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number600176084
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number600176084
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number600176084
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number600176084
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number600176084
License Number StateWA

VIII. Authorized Official

Name: JAMES K COFFEE
Title or Position: CEO
Credential:
Phone: 360-636-3892