Provider Demographics
NPI:1104590504
Name:PENINSULA COMMUNITY HEALTH SERVICES
Entity type:Organization
Organization Name:PENINSULA COMMUNITY HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIBEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NEAONVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-616-3138
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-0212
Mailing Address - Country:US
Mailing Address - Phone:360-377-3776
Mailing Address - Fax:360-373-2096
Practice Address - Street 1:11901 137TH AVE NW UNIT A
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98329-6617
Practice Address - Country:US
Practice Address - Phone:360-377-3776
Practice Address - Fax:360-373-2096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-09
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty