Healthcare Provider Details

I. General information

NPI: 1124135215
Provider Name (Legal Business Name): TRI-STATE MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HIGHLAND AVENUE
CLARKSTON WA
99403
US

IV. Provider business mailing address

PO BOX 187
CLARKSTON WA
99403-0187
US

V. Phone/Fax

Practice location:
  • Phone: 509-758-2568
  • Fax: 509-758-3413
Mailing address:
  • Phone: 509-758-5511
  • Fax: 509-751-9406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number15457
License Number StateWA

VIII. Authorized Official

Name: MR. ALEX C TOWN
Title or Position: CFO
Credential:
Phone: 509-758-4667