Provider Demographics
NPI:1992923064
Name:COLUMBIA BASIN HEALTH ASSOCIATION
Entity type:Organization
Organization Name:COLUMBIA BASIN HEALTH ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NIEVES
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-488-5256
Mailing Address - Street 1:1515 E. COLUMBIA ST.
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344
Mailing Address - Country:US
Mailing Address - Phone:509-488-5256
Mailing Address - Fax:509-488-9939
Practice Address - Street 1:1515 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1846
Practice Address - Country:US
Practice Address - Phone:509-488-5256
Practice Address - Fax:509-488-9939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA152W00000X
WAOD00003794261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8908941OtherCRIME VICTIMS #
WA2029130Medicaid
WA0035900OtherDEPT L&I #
WA7107675OtherUGS MDC DSHS CROSSOVER
WACO3323Medicare ID - Type UnspecifiedRAILROAD MEDICARE #
WA2029130Medicaid