Provider Demographics
NPI:1962876748
Name:COWLITZ FAMILY HEALTH CENTER
Entity type:Organization
Organization Name:COWLITZ FAMILY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:COFFEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-636-3892
Mailing Address - Street 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-636-3892
Mailing Address - Fax:360-232-8400
Practice Address - Street 1:784 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2315
Practice Address - Country:US
Practice Address - Phone:360-703-6400
Practice Address - Fax:360-353-3611
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COWLITZ FAMILY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-17
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600176084261QF0050X, 261QF0400X, 261QM0850X, 261QM0855X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7086523Medicaid
WA1437359551Medicaid
WA7086523Medicaid