Provider Demographics
NPI:1124117197
Name:PROVIDENCE HEALTH & SERVICE WASHINGTON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICE WASHINGTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PAYOR CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-6715
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:425-525-6778
Mailing Address - Fax:425-525-6700
Practice Address - Street 1:1010 SOUTH SCHEUBER RD
Practice Address - Street 2:SUITES 3 & 4
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8892
Practice Address - Country:US
Practice Address - Phone:360-807-7966
Practice Address - Fax:360-807-7977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA71215552Medicaid
WADD5654OtherRR MEDICARE
WA71215552Medicaid