Healthcare Provider Details

I. General information

NPI: 1437657996
Provider Name (Legal Business Name): GEORGE MCLITUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 NE 117TH ST STE 101
VANCOUVER WA
98686-4022
US

IV. Provider business mailing address

2009 NE 117TH ST STE 101
VANCOUVER WA
98686-4022
US

V. Phone/Fax

Practice location:
  • Phone: 360-566-9112
  • Fax:
Mailing address:
  • Phone: 360-566-9112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP00044710
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: