=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215567300
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KITTITAS VALLEY URGENT CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2020
-----------------------------------------------------
Last Update Date | 01/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 E VALLEY MALL BLVD STE 2B
-----------------------------------------------------
City | UNION GAP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98903-1652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-367-8733
-----------------------------------------------------
Fax | 509-361-5015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 E VALLEY MALL BLVD STE 2B
-----------------------------------------------------
City | UNION GAP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98903-1652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-367-8733
-----------------------------------------------------
Fax | 509-361-5015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAUL DAVID WOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-899-6179
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------