Provider Demographics
NPI:1407952369
Name:KLICKITAT COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Entity Type:Organization
Organization Name:KLICKITAT COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Other - Org Name:KVH FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HIEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-773-4022
Mailing Address - Street 1:310 S ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDENDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98620-9201
Mailing Address - Country:US
Mailing Address - Phone:509-773-4022
Mailing Address - Fax:509-773-1941
Practice Address - Street 1:317 SANDERS WAY
Practice Address - Street 2:
Practice Address - City:GOLDENDALE
Practice Address - State:WA
Practice Address - Zip Code:98620-9053
Practice Address - Country:US
Practice Address - Phone:509-773-4017
Practice Address - Fax:509-773-1941
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KLICKITAT COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-16
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7113681Medicaid
WA7113681Medicaid