Provider Demographics
NPI:1104093368
Name:OUR LADY OF LOURDES HEALTH CENTER
Entity type:Organization
Organization Name:OUR LADY OF LOURDES HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-543-2483
Mailing Address - Street 1:520 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5257
Mailing Address - Country:US
Mailing Address - Phone:509-543-9300
Mailing Address - Fax:509-545-5049
Practice Address - Street 1:5304 N ROAD 68
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9189
Practice Address - Country:US
Practice Address - Phone:509-543-9300
Practice Address - Fax:509-545-5049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001692Medicaid
WAG319216500Medicare PIN