Provider Demographics
NPI:1073674040
Name:ENUMCLAW REGIONAL HOSPITAL ASSOCIATION
Entity type:Organization
Organization Name:ENUMCLAW REGIONAL HOSPITAL ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-680-4005
Mailing Address - Street 1:PO BOX 31001-1482
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-1482
Mailing Address - Country:US
Mailing Address - Phone:360-802-3265
Mailing Address - Fax:360-825-9046
Practice Address - Street 1:1455 BATTERSBY AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3634
Practice Address - Country:US
Practice Address - Phone:360-802-3265
Practice Address - Fax:360-825-9046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH035282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3310406Medicaid
WA501335Medicare Oscar/Certification