Healthcare Provider Details

I. General information

NPI: 1164490058
Provider Name (Legal Business Name): CITY OF CASTLE ROCK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 A STREET SW
CASTLE ROCK WA
98611
US

IV. Provider business mailing address

PO BOX 370
CASTLE ROCK WA
98611-0370
US

V. Phone/Fax

Practice location:
  • Phone: 360-274-4413
  • Fax:
Mailing address:
  • Phone: 360-274-4413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number08M01
License Number StateWA

VIII. Authorized Official

Name: ERIC KOREIS
Title or Position: CHIEF
Credential:
Phone: 360-274-4413