Healthcare Provider Details

I. General information

NPI: 1285290338
Provider Name (Legal Business Name): CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 G ST
FORKS WA
98331-9025
US

IV. Provider business mailing address

530 BOGACHIEL WAY
FORKS WA
98331-9120
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-6271
  • Fax: 360-374-9781
Mailing address:
  • Phone: 360-374-6271
  • Fax: 360-374-9781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARIE MICHEAU
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 360-374-6271