Provider Demographics
NPI:1497759203
Name:WALLA WALLA COMMUNITY HOSPICE
Entity Type:Organization
Organization Name:WALLA WALLA COMMUNITY HOSPICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-5561
Mailing Address - Street 1:PO BOX 2026
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0948
Mailing Address - Country:US
Mailing Address - Phone:509-525-5561
Mailing Address - Fax:509-525-3517
Practice Address - Street 1:1067 E ISAACS AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2040
Practice Address - Country:US
Practice Address - Phone:509-525-5561
Practice Address - Fax:509-525-3517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIS-469251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR132121Medicaid
WA3990132Medicaid
OR132121Medicaid