Healthcare Provider Details

I. General information

NPI: 1063646107
Provider Name (Legal Business Name): PULLMAN REGIONAL HOSPITAL CLINIC NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 SE PRO MALL BLVD STE 104
PULLMAN WA
99163-5423
US

IV. Provider business mailing address

840 SE BISHOP BLVD STE 101
PULLMAN WA
99163-5502
US

V. Phone/Fax

Practice location:
  • Phone: 509-332-6139
  • Fax: 509-332-6579
Mailing address:
  • Phone: 509-332-6139
  • Fax: 509-332-6579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number50-3922
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: STEVEN FEBUS
Title or Position: CFO
Credential:
Phone: 509-332-6139