Provider Demographics
NPI:1083947709
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST SEC FOR ENROLLMENT / DIR REIM
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:1615 75TH ST SW STE 210
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-6293
Mailing Address - Country:US
Mailing Address - Phone:425-261-4800
Mailing Address - Fax:425-261-4868
Practice Address - Street 1:1615 75TH ST SW STE 210
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-6293
Practice Address - Country:US
Practice Address - Phone:425-261-4800
Practice Address - Fax:425-261-4868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251G00000X, 315D00000X
WAIHS.FS.00000418251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3990074Medicaid
WA501514Medicare PIN