Healthcare Provider Details

I. General information

NPI: 1891326856
Provider Name (Legal Business Name): MICHAEL C CIVILE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 EASTMONT AVE STE B
EAST WENATCHEE WA
98802-5306
US

IV. Provider business mailing address

3919 NW CASCADE AVE
EAST WENATCHEE WA
98802-9524
US

V. Phone/Fax

Practice location:
  • Phone: 509-885-9090
  • Fax:
Mailing address:
  • Phone: 206-673-1249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: