Healthcare Provider Details

I. General information

NPI: 1184708471
Provider Name (Legal Business Name): OUR LADY OF LOURDES HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 W COURT ST SUITE B
PASCO WA
99301-2879
US

IV. Provider business mailing address

4403 W COURT ST SUITE B
PASCO WA
99301-2879
US

V. Phone/Fax

Practice location:
  • Phone: 509-545-5358
  • Fax:
Mailing address:
  • Phone: 509-545-6620
  • Fax: 509-545-6842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number113003371
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number113003371
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number113003371
License Number StateWA

VIII. Authorized Official

Name: MR. JOHN SERLE
Title or Position: PRESIDENT & CEO
Credential:
Phone: 509-543-2483