Healthcare Provider Details

I. General information

NPI: 1992923064
Provider Name (Legal Business Name): COLUMBIA BASIN HEALTH ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 E COLUMBIA ST
OTHELLO WA
99344-1846
US

IV. Provider business mailing address

1515 E. COLUMBIA ST.
OTHELLO WA
99344
US

V. Phone/Fax

Practice location:
  • Phone: 509-488-5256
  • Fax: 509-488-9939
Mailing address:
  • Phone: 509-488-5256
  • Fax: 509-488-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberOD00003794
License Number StateWA

VIII. Authorized Official

Name: NIEVES GOMEZ
Title or Position: CEO
Credential:
Phone: 509-488-5256