Healthcare Provider Details

I. General information

NPI: 1225363351
Provider Name (Legal Business Name): CEDAR CREST WHOLEHEALTHMEDICALCENTERPLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 10/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CEDAR CREST DR
WINLOCK WA
98596-9791
US

IV. Provider business mailing address

100 CEDAR CREST DR
WINLOCK WA
98596-9791
US

V. Phone/Fax

Practice location:
  • Phone: 360-785-0300
  • Fax: 360-785-3330
Mailing address:
  • Phone: 360-785-0300
  • Fax: 360-785-3330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0028509
License Number StateWA

VIII. Authorized Official

Name: KIM LEIANN TEITZEL
Title or Position: BILLING REPRESENTATIVE
Credential:
Phone: 360-785-0300