Healthcare Provider Details

I. General information

NPI: 1528025293
Provider Name (Legal Business Name): PENINSULA CHILDRENS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 E CAROLINE
PORT ANGELES WA
98362
US

IV. Provider business mailing address

902 E CAROLINE
PORT ANGELES WA
98362
US

V. Phone/Fax

Practice location:
  • Phone: 360-457-8578
  • Fax: 360-457-4841
Mailing address:
  • Phone: 360-457-8578
  • Fax: 360-457-4841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number601481297
License Number StateWA

VIII. Authorized Official

Name: DR. JEFFREY CHARLES WELLER
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 360-457-8578