Healthcare Provider Details

I. General information

NPI: 1962916437
Provider Name (Legal Business Name): PARKVIEW MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S DIVISION ST STE A
MOSES LAKE WA
98837-3800
US

IV. Provider business mailing address

615 S DIVISION ST STE A
MOSES LAKE WA
98837-3800
US

V. Phone/Fax

Practice location:
  • Phone: 509-766-9450
  • Fax:
Mailing address:
  • Phone: 509-766-9450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JILL ANN DUDIK BROSS
Title or Position: OWNER
Credential: MD, FAAP
Phone: 509-766-9450