Provider Demographics
NPI:1447286646
Name:KIRKPATRICK FAMILY CARE, PS
Entity type:Organization
Organization Name:KIRKPATRICK FAMILY CARE, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-430-2911
Mailing Address - Street 1:PO BOX 1338
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-7785
Mailing Address - Country:US
Mailing Address - Phone:360-423-0390
Mailing Address - Fax:360-577-3865
Practice Address - Street 1:1706 WASHINGTON WAY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2952
Practice Address - Country:US
Practice Address - Phone:360-423-0390
Practice Address - Fax:360-577-3865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6004675663261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7097447Medicaid
WAGAB12381Medicare PIN
WA6061010002Medicare NSC