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General NPI Number Information
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NPI Number | 1750434098
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Entity Type | Organization
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Legal Business Name | PROVIDENCE HEALTH SYSTEM OF WASHINGTON
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 500 SE WASHINGTON AVE
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City | CHEHALIS
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State | WA
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Zip | 98532-3058
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Country | US
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Telephone | 360-740-6542
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Fax | 360-740-8367
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Provider Business Mailing Address
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Address Line | 914 S SCHEUBER RD
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City | CENTRALIA
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State | WA
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Zip | 98531-9027
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Country | US
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Telephone | 360-330-8815
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Fax | 360-330-8812
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Authorized Official
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Title or Position | ASSISTANT ADMINISTRATOR
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Name | KEN BOUCHER
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Credential |
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Telephone | 360-330-8541
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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