Provider Demographics
NPI:1417148461
Name:PROVIDENCE HEALTHCARE
Entity Type:Organization
Organization Name:PROVIDENCE HEALTHCARE
Other - Org Name:DEER PARK HOSPITAL CRNA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WICKLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-232-1177
Mailing Address - Street 1:910 N WASHINGTON ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2202
Mailing Address - Country:US
Mailing Address - Phone:509-276-5061
Mailing Address - Fax:
Practice Address - Street 1:1015 E D ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-5067
Practice Address - Country:US
Practice Address - Phone:509-232-1173
Practice Address - Fax:509-232-1165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH 178282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000015OtherFACILITY ID
WAH 178OtherLICENSE
WA9043233Medicaid
WA000015OtherFACILITY ID