Healthcare Provider Details

I. General information

NPI: 1508058520
Provider Name (Legal Business Name): PROVIDENCE HEALTH SYSTEM WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 S SCHEUBER RD
CENTRALIA WA
98531-9027
US

IV. Provider business mailing address

914 S SCHEUBER RD
CENTRALIA WA
98531-9027
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-2803
  • Fax:
Mailing address:
  • Phone: 360-736-2803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number602399531
License Number StateWA

VIII. Authorized Official

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