Healthcare Provider Details

I. General information

NPI: 1073776936
Provider Name (Legal Business Name): LAKE ROOSEVELT COMMUNITY HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 SHORT CUT ROAD
INCHELIUM WA
99138-0290
US

IV. Provider business mailing address

39 SHORT CUT ROAD PO BOX 290
INCHELIUM WA
99138-0290
US

V. Phone/Fax

Practice location:
  • Phone: 509-722-7610
  • Fax:
Mailing address:
  • Phone: 509-722-7610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BILL FOXCROFT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 509-722-7610