=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427429851
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORIAL PHYSICIANS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2015
-----------------------------------------------------
Last Update Date | 10/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 616 RAILROAD AVE SUITE 1 AND 2
-----------------------------------------------------
City | ZILLAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98953-9426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-972-1190
-----------------------------------------------------
Fax | 509-249-4458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3800 SUMMITVIEW AVE
-----------------------------------------------------
City | YAKIMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98902-2715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-248-7849
-----------------------------------------------------
Fax | 509-248-8291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO, VP
-----------------------------------------------------
Name | TIMOTHY REED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-248-7849
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 602902835
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------