Provider Demographics
NPI:1083876130
Name:L G STECK MEMORIAL CLINIC P S
Entity Type:Organization
Organization Name:L G STECK MEMORIAL CLINIC P S
Other - Org Name:NAPAVINE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:BREDESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-740-4001
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:NAPAVINE
Mailing Address - State:WA
Mailing Address - Zip Code:98565-0147
Mailing Address - Country:US
Mailing Address - Phone:360-262-3990
Mailing Address - Fax:360-262-0873
Practice Address - Street 1:305 LINHART AVE NE
Practice Address - Street 2:
Practice Address - City:NAPAVINE
Practice Address - State:WA
Practice Address - Zip Code:98565
Practice Address - Country:US
Practice Address - Phone:360-262-3990
Practice Address - Fax:360-262-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7074131Medicaid
503832AMedicare Oscar/Certification