Healthcare Provider Details

I. General information

NPI: 1083947709
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 75TH ST SW STE 210
EVERETT WA
98203-6293
US

IV. Provider business mailing address

1615 75TH ST SW STE 210
EVERETT WA
98203-6293
US

V. Phone/Fax

Practice location:
  • Phone: 425-261-4800
  • Fax: 425-261-4868
Mailing address:
  • Phone: 425-261-4800
  • Fax: 425-261-4868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License NumberIHS.FS.00000418
License Number StateWA

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY ENROLLMENT
Credential:
Phone: 425-358-9786