MEDICARE: QUALICENTERS INLAND NORTHWEST, LLC

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1215196787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUALICENTERS INLAND NORTHWEST, LLC

Provider Business Mailing Address
First Line	:	5616 OCEAN BEACH HWY
Second Line	:	SUITE 260
City	:	LONGVIEW
State	:	WA
Zip	:	98632-6222
Country	:	US
Telephone Number	:	360-425-2460
Fax Number	:

Provider Business Practice Location Address
First Line	:	5616 OCEAN BEACH HWY
Second Line	:	SUITE 260
City	:	LONGVIEW
State	:	WA
Zip	:	98632-6222
Country	:	US
Telephone Number	:	360-425-2460
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	MARK FAWCETT
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	08/02/2012

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