=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770714693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE HEALTH & SERVICES WASHINGTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2009
-----------------------------------------------------
Last Update Date | 05/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 508 1/2 EIGHTH STREET
-----------------------------------------------------
City | HOQUIAM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98550-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-533-8813
-----------------------------------------------------
Fax | 360-533-1016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 34439
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98124-1439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-525-6778
-----------------------------------------------------
Fax | 425-525-6700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECREATRY FOR ENROLLMENT
-----------------------------------------------------
Name | DONALD WAYNE ANDERSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-358-9786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 276400000X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------