Provider Demographics
NPI:1508924275
Name:KITTITAS COUNTY PUBLIC HEALTH
Entity Type:Organization
Organization Name:KITTITAS COUNTY PUBLIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-962-7515
Mailing Address - Street 1:507 N NANUM ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926
Mailing Address - Country:US
Mailing Address - Phone:509-962-7515
Mailing Address - Fax:509-962-7581
Practice Address - Street 1:507 N NANUM ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926
Practice Address - Country:US
Practice Address - Phone:509-962-7515
Practice Address - Fax:509-962-7581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7305204Medicaid
WA7401169Medicaid
WAG000304878Medicare ID - Type Unspecified