Provider Demographics
NPI:1063521862
Name:WALLA WALLA CLINIC, INC.
Entity type:Organization
Organization Name:WALLA WALLA CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-3720
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1592
Practice Address - Street 1:10 NE 5TH AVE
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862-1702
Practice Address - Country:US
Practice Address - Phone:541-938-3314
Practice Address - Fax:541-938-4449
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALLA WALLA CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-29
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR383863Medicare Oscar/Certification
OR0447920002Medicare NSC
ORR0000WCHPCMedicare PIN
WAG001346600Medicare PIN