=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760485221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-STATE MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2005
-----------------------------------------------------
Last Update Date | 03/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1221 HIGHLAND AVE
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99403-2829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-758-5511
-----------------------------------------------------
Fax | 509-751-9406
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1221 HIGHLAND AVE
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99403-2829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-758-5511
-----------------------------------------------------
Fax | 509-751-9406
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. ALEX C TOWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-758-4667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number | H-108
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------