Provider Demographics
NPI:1093006447
Name:OUR LADY OF LOURDES HEALTH CENTER
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES HEALTH CENTER
Other - Org Name:LOURDES 14TH AVENUE MEDICAL GROUP
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:509-543-2483
Mailing Address - Street 1:1200 N 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-4182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-4182
Practice Address - Country:US
Practice Address - Phone:509-547-7704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty