Provider Demographics
NPI:1215023015
Name:ST MARY MEDICAL CENTER
Entity Type:Organization
Organization Name:ST MARY MEDICAL CENTER
Other - Org Name:TCU SKILLED NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARENTEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-3320
Mailing Address - Street 1:PO BOX 1477
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362
Mailing Address - Country:US
Mailing Address - Phone:509-522-5900
Mailing Address - Fax:509-522-5578
Practice Address - Street 1:401 W POPLAR
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-522-5870
Practice Address - Fax:509-522-5751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH050314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR800026OtherMEDICAID
WA4212015Medicaid
WA204884OtherL & I
505497Medicare ID - Type Unspecified