Healthcare Provider Details

I. General information

NPI: 1457581936
Provider Name (Legal Business Name): KITTITAS COUNTY PUBLIC HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 E MANITOBA AVE
ELLENSBURG WA
98926-3842
US

IV. Provider business mailing address

716 E MANITOBA AVE
ELLENSBURG WA
98926-3875
US

V. Phone/Fax

Practice location:
  • Phone: 509-925-3151
  • Fax: 509-925-4382
Mailing address:
  • Phone: 509-925-3151
  • Fax: 509-925-4382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 00175254
License Number StateWA

VIII. Authorized Official

Name: HAROLD BROCKMAN
Title or Position: CFO
Credential:
Phone: 509-962-7351