Provider Demographics
NPI:1417057233
Name:PROVIDENCE HEALTH CARE
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH CARE
Other - Org Name:DEER PARK HEALTH CENTER & HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FEBACH
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:509-276-5061
Mailing Address - Street 1:1015 EAST D STREET
Mailing Address - Street 2:P O BOX 742
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-0742
Mailing Address - Country:US
Mailing Address - Phone:509-276-5061
Mailing Address - Fax:509-276-8713
Practice Address - Street 1:1015 EAST D STREET
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-0742
Practice Address - Country:US
Practice Address - Phone:509-276-5061
Practice Address - Fax:509-276-8713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-178282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA501306Medicare ID - Type UnspecifiedPROVIDER NUMBER