Provider Demographics
NPI:1083832802
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE LIFELINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-563-0130
Mailing Address - Street 1:4001 DALE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5428
Mailing Address - Country:US
Mailing Address - Phone:907-563-0130
Mailing Address - Fax:907-563-0135
Practice Address - Street 1:4001 DALE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5428
Practice Address - Country:US
Practice Address - Phone:907-563-0130
Practice Address - Fax:907-563-0135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMS0012Medicaid