Provider Demographics
NPI:1962592295
Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASST CORP SEC FOR ENROLLMENTS
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 24666
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0666
Mailing Address - Country:US
Mailing Address - Phone:503-893-7120
Mailing Address - Fax:425-276-3215
Practice Address - Street 1:4200 6TH AVE SE
Practice Address - Street 2:SUITE 201
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1042
Practice Address - Country:US
Practice Address - Phone:360-459-8311
Practice Address - Fax:360-493-4657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIS-420251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3990355Medicaid
WA3990355Medicaid