Provider Demographics
NPI:1073524690
Name:LINCOLN COUNTY PUBLIC HOSPITAL DISTRICT 1
Entity Type:Organization
Organization Name:LINCOLN COUNTY PUBLIC HOSPITAL DISTRICT 1
Other - Org Name:ODESSA MEMORIAL HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-982-2611
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:WA
Mailing Address - Zip Code:99159-0368
Mailing Address - Country:US
Mailing Address - Phone:509-982-2611
Mailing Address - Fax:509-982-2159
Practice Address - Street 1:502 E. AMENDE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:WA
Practice Address - Zip Code:99159
Practice Address - Country:US
Practice Address - Phone:509-982-2611
Practice Address - Fax:509-982-2159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH080282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0007015OtherLABOR & INDUSTRIES
200814200814OtherPREMERA
WA3310505Medicaid
WA0007015OtherLABOR & INDUSTRIES