Provider Demographics
NPI:1447342373
Name:PROVIDENCE HEALTH CARE
Entity type:Organization
Organization Name:PROVIDENCE HEALTH CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WALSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-428-2367
Mailing Address - Street 1:5633 N LIDGERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-1224
Mailing Address - Country:US
Mailing Address - Phone:509-482-0111
Mailing Address - Fax:509-482-3052
Practice Address - Street 1:5633 N LIDGERWOOD ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1224
Practice Address - Country:US
Practice Address - Phone:509-482-0111
Practice Address - Fax:509-482-3052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9611674Medicaid
WA7401045Medicaid
WA7031719Medicaid
WA3300126Medicaid
WA500077Medicare ID - Type UnspecifiedMEDICARE 837I
WA000381050Medicare ID - Type UnspecifiedCRNA
WA7031719Medicaid