Provider Demographics
NPI:1376536136
Name:CASCADE FAMILY MEDICAL CLINIC INC PS
Entity Type:Organization
Organization Name:CASCADE FAMILY MEDICAL CLINIC INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:YARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-736-7623
Mailing Address - Street 1:1740 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9071
Mailing Address - Country:US
Mailing Address - Phone:360-736-7623
Mailing Address - Fax:360-736-4074
Practice Address - Street 1:1740 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9071
Practice Address - Country:US
Practice Address - Phone:360-736-7623
Practice Address - Fax:360-736-4074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600344469207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7089634Medicaid
WA0031980OtherL & I
WA0031980OtherL & I
WAG115142000Medicare UPIN