=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194334789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C&L, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2020
-----------------------------------------------------
Last Update Date | 02/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7514 W YELLOWSTONE AVE
-----------------------------------------------------
City | KENNEWICK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99336-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-783-7242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7514 W YELLOWSTONE AVE
-----------------------------------------------------
City | KENNEWICK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99336-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-783-7242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | COLTON WARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-783-7242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------