Healthcare Provider Details

I. General information

NPI: 1518334523
Provider Name (Legal Business Name): PUBLIC HOSPITAL DISTRICT 3 OF PACIFIC COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 1ST AVE S
ILWACO WA
98624-9100
US

IV. Provider business mailing address

PO BOX N
ILWACO WA
98624-0319
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-2662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH079
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberH079
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberH079
License Number StateWA

VIII. Authorized Official

Name: LARRY COHEN
Title or Position: CEO
Credential:
Phone: 360-642-6301