Healthcare Provider Details

I. General information

NPI: 1316079585
Provider Name (Legal Business Name): YAKIMA MEDICAL CLINIC INC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 HOLTON AVE
YAKIMA WA
98902
US

IV. Provider business mailing address

310 HOLTON AVE
YAKIMA WA
98902
US

V. Phone/Fax

Practice location:
  • Phone: 509-452-2508
  • Fax: 509-452-7316
Mailing address:
  • Phone: 509-452-2508
  • Fax: 509-452-7316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number0P00001175
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0P00001175
License Number StateWA

VIII. Authorized Official

Name: T KENT VYE
Title or Position: PRESIDENT
Credential: DO
Phone: 509-452-2508