Provider Demographics
NPI:1467610972
Name:CLINICARE OF PORT ANGELES INC
Entity Type:Organization
Organization Name:CLINICARE OF PORT ANGELES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DECK
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-452-5000
Mailing Address - Street 1:621 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3319
Mailing Address - Country:US
Mailing Address - Phone:360-452-5000
Mailing Address - Fax:360-452-0228
Practice Address - Street 1:621 E FRONT ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3319
Practice Address - Country:US
Practice Address - Phone:360-452-5000
Practice Address - Fax:360-452-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601555884261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7065543Medicaid
WA71530OtherWA STATE L&I