Healthcare Provider Details

I. General information

NPI: 1952963704
Provider Name (Legal Business Name): PENINSULA COMMUNITY HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 NW BUCKLIN HILL RD STE 202
SILVERDALE WA
98383-8362
US

IV. Provider business mailing address

PO BOX 960
BREMERTON WA
98337-0212
US

V. Phone/Fax

Practice location:
  • Phone: 360-377-3776
  • Fax:
Mailing address:
  • Phone: 360-377-3776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JA-ANGEL DEWALT
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 360-475-6711