Healthcare Provider Details

I. General information

NPI: 1659505840
Provider Name (Legal Business Name): OUR LADY OF LOURDES HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 WRIGLEY DRIVE
PASCO WA
99301
US

IV. Provider business mailing address

7425 WRIGLEY DRIVE
PASCO WA
99301
US

V. Phone/Fax

Practice location:
  • Phone: 509-545-6220
  • Fax: 509-545-6842
Mailing address:
  • Phone: 509-545-6220
  • 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 Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number113003371
License Number StateWA

VIII. Authorized Official

Name: JOHN SERLE
Title or Position: CEO
Credential:
Phone: 509-543-2483