=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538413109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE HEALTH & SERVICES WASHINGTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2012
-----------------------------------------------------
Last Update Date | 05/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 S MEYERS ST
-----------------------------------------------------
City | KETTLE FALLS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99141-7005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-685-7848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31001-4114
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91110-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-685-7848
-----------------------------------------------------
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 | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------