Healthcare Provider Details

I. General information

NPI: 1720276207
Provider Name (Legal Business Name): RICHARD L. DICKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 WEST E ST
FORKS WA
98331
US

IV. Provider business mailing address

PO BOX 1918
FORKS WA
98331
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-6642
  • Fax: 360-374-5335
Mailing address:
  • Phone: 360-374-6642
  • Fax: 360-374-5335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateWA

VIII. Authorized Official

Name: MR. RICHARD L DICKSON
Title or Position: OWNER PHYSICIAN
Credential: MD
Phone: 360-374-6642