Provider Demographics
NPI:1194887588
Name:PROVIDENCE HEALTH CARE
Entity type:Organization
Organization Name:PROVIDENCE HEALTH CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPPOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:509-482-2475
Mailing Address - Street 1:6018 N ASTOR ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-1107
Mailing Address - Country:US
Mailing Address - Phone:509-482-2475
Mailing Address - Fax:509-482-2490
Practice Address - Street 1:6018 N ASTOR ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1107
Practice Address - Country:US
Practice Address - Phone:509-482-2475
Practice Address - Fax:509-482-2490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA425223Medicaid