Provider Demographics
NPI:1194038455
Name:PROVIDENCE PHYSICIAN SERVICES CO
Entity Type:Organization
Organization Name:PROVIDENCE PHYSICIAN SERVICES CO
Other - Org Name:PROVIDENCE VALLEY FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-482-2367
Mailing Address - Street 1:PO BOX 34908
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12509 E MISSION AVE
Practice Address - Street 2:STE 102
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1049
Practice Address - Country:US
Practice Address - Phone:509-938-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PHYSICIAN SERVICES CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty