Provider Demographics
NPI:1073572855
Name:LAKE CHELAN CLINIC, P.C.
Entity Type:Organization
Organization Name:LAKE CHELAN CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-682-2511
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-0368
Mailing Address - Country:US
Mailing Address - Phone:509-682-2511
Mailing Address - Fax:509-682-2515
Practice Address - Street 1:219 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-9160
Practice Address - Country:US
Practice Address - Phone:509-682-2511
Practice Address - Fax:509-682-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA503851261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7115603Medicaid
WA7115603Medicaid