Healthcare Provider Details

I. General information

NPI: 1912235060
Provider Name (Legal Business Name): MOLINA HEALTHCARE OF WASHINGTON, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 BROADWAY, SUITE 200
EVERETT WA
98201-4425
US

IV. Provider business mailing address

200 OCEANGATE, SUITE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 562-499-6191
  • Fax: 562-499-6171
Mailing address:
  • Phone: 562-499-6191
  • Fax: 562-499-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GLORIA CALDERON
Title or Position: VP CLINIC OPERATIONS
Credential:
Phone: 562-499-6191