Healthcare Provider Details

I. General information

NPI: 1639113830
Provider Name (Legal Business Name): LINCOLN COUNTY HOSPITAL DISTRICT 3
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/18/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 E BROADWAY AVE
REARDAN WA
99029
US

IV. Provider business mailing address

10 NICHOLLS ST
DAVENPORT WA
99122-9729
US

V. Phone/Fax

Practice location:
  • Phone: 509-796-2737
  • Fax: 509-796-2738
Mailing address:
  • Phone: 509-725-7501
  • Fax: 509-725-7504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH-137
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TYSON E LACY
Title or Position: CEO, ADMINISTRATOR
Credential:
Phone: 509-725-7101