Provider Demographics
NPI:1316147549
Name:VANCOUVER ENT & ENT OF THE NORTHWEST, PLLC
Entity type:Organization
Organization Name:VANCOUVER ENT & ENT OF THE NORTHWEST, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICE SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:T
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-449-6613
Mailing Address - Street 1:1405 SE 164TH AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9644
Mailing Address - Country:US
Mailing Address - Phone:360-256-4425
Mailing Address - Fax:360-260-7249
Practice Address - Street 1:1405 SE 164TH AVE
Practice Address - Street 2:STE 102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9644
Practice Address - Country:US
Practice Address - Phone:360-256-4425
Practice Address - Fax:360-260-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9059056Medicaid