Healthcare Provider Details

I. General information

NPI: 1205931508
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18313 PAULSON ST SW SUITE A
ROCHESTER WA
98579-9262
US

IV. Provider business mailing address

PO BOX 31001-4114
PASADENA CA
91110-4114
US

V. Phone/Fax

Practice location:
  • Phone: 360-827-8400
  • Fax: 360-273-7301
Mailing address:
  • Phone: 503-893-7120
  • Fax: 425-276-3215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASST CORP SEC FOR ENROLLMENTS
Credential:
Phone: 425-358-9786