Provider Demographics
NPI:1093889875
Name:PUBLIC HOSPITAL DIST NO 1 SKAGIT
Entity Type:Organization
Organization Name:PUBLIC HOSPITAL DIST NO 1 SKAGIT
Other - Org Name:SKAGIT VALLEY KIDNEY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ISHIZUKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-814-8346
Mailing Address - Street 1:1415 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4126
Mailing Address - Country:US
Mailing Address - Phone:360-424-4111
Mailing Address - Fax:
Practice Address - Street 1:208 S. HOSPITAL PARKWAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4126
Practice Address - Country:US
Practice Address - Phone:360-424-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-207261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1002366Medicaid
WA1002366Medicaid