Healthcare Provider Details

I. General information

NPI: 1760411912
Provider Name (Legal Business Name): YAKIMA VALLEY PROFESSIONAL SERVICES ON TIETON, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S. 72ND AVE
YAKIMA WA
98908
US

IV. Provider business mailing address

PO BOX 2947
YAKIMA WA
98907-2947
US

V. Phone/Fax

Practice location:
  • Phone: 509-972-1818
  • Fax: 509-972-7842
Mailing address:
  • Phone: 509-248-7849
  • Fax: 509-249-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMD00027321
License Number StateWA

VIII. Authorized Official

Name: JIM SIMMONS
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 509-248-7849