Healthcare Provider Details

I. General information

NPI: 1134573272
Provider Name (Legal Business Name): PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 N 13TH LOOP RD
SHELTON WA
98584-2169
US

IV. Provider business mailing address

1812 N 13TH LOOP RD
SHELTON WA
98584-2169
US

V. Phone/Fax

Practice location:
  • Phone: 360-426-3862
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. ERIC MOLL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 360-427-9556