Healthcare Provider Details

I. General information

NPI: 1871810945
Provider Name (Legal Business Name): PEACEHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 OCEAN BEACH HWY STE. 200
LONGVIEW WA
98632-4082
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT. 364
VANCOUVER WA
98683-9324
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-6900
  • Fax:
Mailing address:
  • Phone: 360-414-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. TOM HAYWOOD
Title or Position: NETWORK CFO
Credential:
Phone: 360-414-2000