Provider Demographics
NPI:1003006008
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:HOLY FAMILY MATERNITY SUPPORT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HASSELBLAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-464-7107
Mailing Address - Street 1:910 N WASHINGTON ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2260
Mailing Address - Country:US
Mailing Address - Phone:509-232-1173
Mailing Address - Fax:509-232-1196
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:509-482-2456
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-26
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH139171M00000X
WAH 139282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7401045Medicaid
500077Medicare Oscar/Certification