Provider Demographics
NPI:1003212895
Name:HEALTHSOURCE OF MOSES LAKE
Entity Type:Organization
Organization Name:HEALTHSOURCE OF MOSES LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:MOYLE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-765-0638
Mailing Address - Street 1:420 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1908
Mailing Address - Country:US
Mailing Address - Phone:509-765-0638
Mailing Address - Fax:509-765-3891
Practice Address - Street 1:420 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1908
Practice Address - Country:US
Practice Address - Phone:509-765-0638
Practice Address - Fax:509-765-3891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003167261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1598852840Medicare UPIN