MEDICARE: PROVIDENCE HEALTH & SERVICES WASHINGTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	IS-420	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063415198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HEALTH & SERVICES WASHINGTON

Provider Business Mailing Address
First Line	:	PO BOX 24666
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98124-0666
Country	:	US
Telephone Number	:	503-893-7120
Fax Number	:	425-276-3215

Provider Business Practice Location Address
First Line	:	4200 6TH AVE SE
Second Line	:	SUITE 201
City	:	LACEY
State	:	WA
Zip	:	98503-1042
Country	:	US
Telephone Number	:	360-459-8311
Fax Number	:	360-493-4657

Authorized Official
Title or Position	:	ASSISTANT SECRETARY ENROLLMENTS
Name	:	DONALD ANDERSON JR.
Credential	:
Telephone Number	:	425-358-9786

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	05/16/2025

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Directions to “PROVIDENCE HEALTH & SERVICES WASHINGTON ” Practice Location

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