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General NPI Number Information
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NPI Number | 1790703106
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Entity Type | Organization
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Legal Business Name | COUNTRY CLINIC
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 1116 HWY 20
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City | WINTHROP
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State | WA
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Zip | 98862
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Country | US
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Telephone | 509-996-8180
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Fax | 509-996-3374
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Provider Business Mailing Address
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Address Line | PO BOX 945
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City | WINTHROP
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State | WA
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Zip | 98862-0945
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Country | US
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Telephone | 509-996-8180
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Fax | 509-996-3374
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Authorized Official
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Title or Position | PHYSICIAN PARTNER
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Name | ANN DIAMOND
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Credential | MD
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Telephone | 509-996-8180
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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 | MD00033304
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License Number State | WA
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