Healthcare Provider Details

I. General information

NPI: 1851348999
Provider Name (Legal Business Name): LONGVIEW VA CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 1ST AVE SUITE 4C
LONGVIEW WA
98632-3270
US

IV. Provider business mailing address

1801 1ST AVE SUITE 4C
LONGVIEW WA
98632-3270
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-7822
  • Fax: 360-636-7893
Mailing address:
  • Phone: 360-636-7822
  • Fax: 360-636-7893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARBARA MAYERICK
Title or Position: DIRECTOR, BUSINESS DEVELOPMENT
Credential:
Phone: 202-254-0339