Provider Demographics
NPI:1225363351
Name:CEDAR CREST WHOLEHEALTHMEDICALCENTERPLLC
Entity Type:Organization
Organization Name:CEDAR CREST WHOLEHEALTHMEDICALCENTERPLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LEIANN
Authorized Official - Last Name:TEITZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-785-0300
Mailing Address - Street 1:100 CEDAR CREST DR
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-9791
Mailing Address - Country:US
Mailing Address - Phone:360-785-0300
Mailing Address - Fax:360-785-3330
Practice Address - Street 1:100 CEDAR CREST DR
Practice Address - Street 2:
Practice Address - City:WINLOCK
Practice Address - State:WA
Practice Address - Zip Code:98596-9791
Practice Address - Country:US
Practice Address - Phone:360-785-0300
Practice Address - Fax:360-785-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0028509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7117534Medicaid
WA7117534Medicaid