NPIViewer - Provider NPI 1194091637

NPI:	1194091637
Name:	N W PEDIATRIC CENTER, INC. P.S.
Entity type:	Organization
Organization Name:	N W PEDIATRIC CENTER, INC. P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:	PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:	LISA
Authorized Official - Middle Name:	GAIL
Authorized Official - Last Name:	MCKAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:	360-736-6777
Mailing Address - Street 1:	1911 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:	CENTRALIA
Mailing Address - State:	WA
Mailing Address - Zip Code:	98531-9073
Mailing Address - Country:	US
Mailing Address - Phone:	360-736-6778
Mailing Address - Fax:	360-736-6552
Practice Address - Street 1:	18313 PAULSON ST SW
Practice Address - Street 2:
Practice Address - City:	ROCHESTER
Practice Address - State:	WA
Practice Address - Zip Code:	98579-9262
Practice Address - Country:	US
Practice Address - Phone:	360-736-6778
Practice Address - Fax:	360-736-6552
EIN:	<UNAVAIL>
Is Organization Subpart?:	Yes
Parent Organization LBN:	N.W.PEDIATRIC CENTER INC PS
Parent Organization TIN:	<UNAVAIL>
Enumeration Date:	2012-03-29
Last Update Date:	2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:

Primary?	Code	Type	Classification	Specialization	Group
Yes	208000000X	Allopathic & Osteopathic Physicians	Pediatrics		Group - Multi-Specialty
No	133V00000X	Dietary & Nutritional Service Providers	Dietitian, Registered		Group - Multi-Specialty
No	2084P0804X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Child & Adolescent Psychiatry	Group - Multi-Specialty
No	363LP0200X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Pediatrics	Group - Multi-Specialty

State	Identifier ID	ID Type
WI	8349342	Medicaid
WI	1058825	Medicaid
WA	8488298	Medicaid
WA	9636994	Medicaid
WA	1072958	Medicaid
WA	9653551	Medicaid
WA	9661323	Medicaid
WA	8141947	Medicaid
WA	8251324	Medicaid
WA	9643156	Medicaid
WA	8173882	Medicaid
WA	8398356	Medicaid
WA	961422	Medicaid
WA	2010815	Medicaid