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General NPI Number Information
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NPI Number | 1679649248
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Entity Type | Organization
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Legal Business Name | BLUE MOUNTAIN FAMILY HEALTH PLLC
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Dates
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Enumeration Date | 11/27/2006
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Last Update Date | 05/21/2024
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Provider Practice Location Address
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Address Line | 1268 BRIDGE ST
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City | CLARKSTON
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State | WA
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Zip | 99403-2219
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Country | US
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Telephone | 509-751-5500
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Fax | 509-751-1059
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Provider Business Mailing Address
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Address Line | 1268 BRIDGE ST
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City | CLARKSTON
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State | WA
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Zip | 99403-2219
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Country | US
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Telephone | 509-751-5500
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Fax | 509-751-1059
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KEVIN JAMES BLACK
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Credential |
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Telephone | 509-751-5500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD00045393
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License Number State | WA
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