Healthcare Provider Details

I. General information

NPI: 1699704676
Provider Name (Legal Business Name): MID-COLUMBIA FAMILY PHYSICIANS,P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 11/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65371 HIGHWAY 14
WHITE SALMON WA
98672-9867
US

IV. Provider business mailing address

PO BOX 1519
WHITE SALMON WA
98672-1519
US

V. Phone/Fax

Practice location:
  • Phone: 509-493-2133
  • Fax: 509-493-9544
Mailing address:
  • Phone: 509-493-2133
  • Fax: 509-493-9544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number600416746
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateWA

VIII. Authorized Official

Name: DR. R ALLEN LABERGE
Title or Position: PRESIDENT
Credential: MD
Phone: 509-493-2133