Provider Demographics
NPI:1437259165
Name:CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT 2
Entity Type:Organization
Organization Name:CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT 2
Other - Org Name:OLYMPIC MEDICAL HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-417-7162
Mailing Address - Street 1:939 CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3909
Mailing Address - Country:US
Mailing Address - Phone:360-417-7000
Mailing Address - Fax:360-417-7602
Practice Address - Street 1:801 E FRONT ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3636
Practice Address - Country:US
Practice Address - Phone:360-417-7315
Practice Address - Fax:360-452-3531
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT 2
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-23
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIS-393251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9039363Medicaid
WA109487OtherLABOR & INDUSTRIES/HH
WA109487OtherLABOR & INDUSTRIES/HH
WA=========OtherTAX ID