Healthcare Provider Details

I. General information

NPI: 1376921627
Provider Name (Legal Business Name): PEACEHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NE MOTHER JOSEPH PL
VANCOUVER WA
98664-3200
US

IV. Provider business mailing address

200 NE MOTHER JOSEPH PL
VANCOUVER WA
98664-3299
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-7550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: STEVEN HOLT
Title or Position: DELEGATED OFFICIAL
Credential:
Phone: 360-514-7044