=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457493447
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAYS HARBOR COUNTY FIRE PROTECTION DISTRICT #4
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 01/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6116 US HIGHWAY 101
-----------------------------------------------------
City | AMANDA PARK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-288-2611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8
-----------------------------------------------------
City | QUINAULT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98575-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-288-2611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | MICHELLE MORRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-288-2611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 14D04
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------