=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366658858
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE HEALTH & SERVICES WASHINGTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 05/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1838 CHICHENOF ST
-----------------------------------------------------
City | KODIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99615-6519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-486-3281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1915 E REZANOF DR
-----------------------------------------------------
City | KODIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99615-6602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECRETARY OF ENROLLMENTS
-----------------------------------------------------
Name | DONALD W ANDERSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-358-9786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 309115
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------