=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891724506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COWLITZ FAMILY HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 05/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1057 12TH AVE
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98632-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-636-3892
-----------------------------------------------------
Fax | 360-414-1342
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1057 12TH AVE
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98632-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-636-3892
-----------------------------------------------------
Fax | 360-414-1114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JAMES K COFFEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-353-5803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0050X
-----------------------------------------------------
Taxonomy Name | Non-Surgical Family Planning Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------