Provider Demographics
NPI:1447401260
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE ST MARY TCU
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF FINANCE RC MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLUMBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-522-5290
Mailing Address - Street 1:PO BOX 1477
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0312
Mailing Address - Country:US
Mailing Address - Phone:509-522-5906
Mailing Address - Fax:509-522-5789
Practice Address - Street 1:401 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2846
Practice Address - Country:US
Practice Address - Phone:509-522-5870
Practice Address - Fax:509-522-5751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-050314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA204884OtherL&I STATE
WA4212015Medicaid
WA4212015Medicaid