Provider Demographics
NPI:1528025293
Name:PENINSULA CHILDRENS CLINIC INC
Entity Type:Organization
Organization Name:PENINSULA CHILDRENS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-457-8578
Mailing Address - Street 1:902 E CAROLINE
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362
Mailing Address - Country:US
Mailing Address - Phone:360-457-8578
Mailing Address - Fax:360-457-4841
Practice Address - Street 1:902 E CAROLINE
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362
Practice Address - Country:US
Practice Address - Phone:360-457-8578
Practice Address - Fax:360-457-4841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601481297261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7058894OtherDSHS