Provider Demographics
NPI:1033106687
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE CENTRALIA HOSPITAL - TRANSITIONAL CARE UNIT
Other - Org Type:Other Name
Authorized Official - Title/Position:PAYOR CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-6715
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:PBO/CREDENTIALING
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:425-525-6778
Mailing Address - Fax:425-525-6700
Practice Address - Street 1:914 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9027
Practice Address - Country:US
Practice Address - Phone:360-330-8703
Practice Address - Fax:360-330-8706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4211918314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA505025Medicare Oscar/Certification
WAG505025Medicare Oscar/Certification
WA505025Medicare PIN