=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205104593
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PULLMAN REGIONAL HOSPITAL CLINIC NETWORK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2011
-----------------------------------------------------
Last Update Date | 06/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 S BLAINE ST STE 5
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-3973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-882-2247
-----------------------------------------------------
Fax | 509-336-7482
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 840 SE BISHOP BLVD STE 101
-----------------------------------------------------
City | PULLMAN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99163-5502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-332-6139
-----------------------------------------------------
Fax | 509-332-6579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC ADMINISTRATOR
-----------------------------------------------------
Name | GROVER 'PETE' C PETERS III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-332-6139
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | 13-3860
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------