Healthcare Provider Details

I. General information

NPI: 1952500209
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 COOKS HILL RD SUITE E
CENTRALIA WA
98531-9072
US

IV. Provider business mailing address

PO BOX 34439
SEATTLE WA
98124-1439
US

V. Phone/Fax

Practice location:
  • Phone: 360-330-8626
  • Fax: 360-807-7983
Mailing address:
  • Phone: 425-525-6778
  • Fax: 425-525-6700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE QUINN
Title or Position: PAYOR CREDENTIALING MANAGER
Credential:
Phone: 425-525-6715