Healthcare Provider Details

I. General information

NPI: 1972517704
Provider Name (Legal Business Name): YAKIMA VALLEY PROFESSIONAL SERVICES ON TIETON, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W NACHES AVE
SELAH WA
98942-1326
US

IV. Provider business mailing address

PO BOX 2947
YAKIMA WA
98907-2947
US

V. Phone/Fax

Practice location:
  • Phone: 509-697-5511
  • Fax: 509-697-9313
Mailing address:
  • Phone: 509-248-7849
  • Fax: 509-249-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JIM SIMMONS
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 509-248-7849