Healthcare Provider Details

I. General information

NPI: 1528267804
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 S SCHEUBER RD
CENTRALIA WA
98531-9027
US

IV. Provider business mailing address

909 N BROADWAY PBO/CREDENTIALING
EVERETT WA
98201-1409
US

V. Phone/Fax

Practice location:
  • Phone: 360-330-8880
  • Fax:
Mailing address:
  • Phone: 425-317-0246
  • Fax: 425-317-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number602399531
License Number StateWA

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY ENROLLMENT
Credential:
Phone: 425-358-9786