Provider Demographics
NPI:1467530915
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:
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:509-773-4022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA202000768261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7076862Medicaid
WA7076862Medicaid