Healthcare Provider Details

I. General information

NPI: 1063415198
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 6TH AVE SE SUITE 201
LACEY WA
98503-1042
US

IV. Provider business mailing address

PO BOX 24666
SEATTLE WA
98124-0666
US

V. Phone/Fax

Practice location:
  • Phone: 360-459-8311
  • Fax: 360-493-4657
Mailing address:
  • Phone: 503-893-7120
  • Fax: 425-276-3215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberIS-420
License Number StateWA

VIII. Authorized Official

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