Healthcare Provider Details

I. General information

NPI: 1194973628
Provider Name (Legal Business Name): MARYS CORNER MEDICAL CLINIC INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4254 JACKSON HWY
CHEHALIS WA
98532
US

IV. Provider business mailing address

4254 JACKSON HWY.
CHEHALIS WA
98532
US

V. Phone/Fax

Practice location:
  • Phone: 360-262-3966
  • Fax: 360-262-3967
Mailing address:
  • Phone: 360-262-3966
  • Fax: 360-262-3967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00039760
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberOP00000823
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberMD00039760
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberAP30005675
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberPA0004588
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004588
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP30005675
License Number StateWA
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00000823
License Number StateWA

VIII. Authorized Official

Name: MISS KIMBERLY HOPE INGLIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-262-3966