Provider Demographics
NPI:1477789956
Name:NORTHWEST PEDIATRIC CENTER, INC. P.S.
Entity Type:Organization
Organization Name:NORTHWEST PEDIATRIC CENTER, INC. P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:MCKAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-736-6778
Mailing Address - Street 1:1911 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9073
Mailing Address - Country:US
Mailing Address - Phone:360-736-6778
Mailing Address - Fax:360-736-6552
Practice Address - Street 1:193 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3037
Practice Address - Country:US
Practice Address - Phone:360-736-6778
Practice Address - Fax:360-736-6552
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST PEDIATRIC CENTER, INC. P.S.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-10
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043677208000000X
WAMD00048049208000000X
WAMD00038226208000000X
WAMD00029916208000000X
WAMD00027525208000000X
WAMD00028578208000000X
WAMD00032554208000000X
WAMD000393512084P0804X
WAAP30007039364SP0200X
WAAP30006273364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA751514OtherMEDICAID ENHANCEMENT CHEHALIS