Provider Demographics
NPI:1447402839
Name:PROVIDENCE HEALTH & SERVICES - WA
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:PO BOX 31001-4110
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4110
Mailing Address - Country:US
Mailing Address - Phone:509-935-8211
Mailing Address - Fax:
Practice Address - Street 1:500 E WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-9523
Practice Address - Country:US
Practice Address - Phone:509-935-8211
Practice Address - Fax:509-935-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA50Z309Medicare Oscar/Certification