Provider Demographics
NPI:1538497417
Name:COWLITZ FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:COWLITZ FAMILY HEALTH CENTER
Other - Org Name:FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-636-3892
Mailing Address - Street 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-636-3892
Mailing Address - Fax:360-414-1114
Practice Address - Street 1:335 UNA AVE
Practice Address - Street 2:
Practice Address - City:CATHLAMET
Practice Address - State:WA
Practice Address - Zip Code:98612-9583
Practice Address - Country:US
Practice Address - Phone:360-465-2990
Practice Address - Fax:360-414-1114
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-03
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600176084261Q00000X, 261QF0050X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7900426Medicaid
WA50-1922OtherMEDICARE PTAN
WA7086523Medicaid
WA7407349Medicaid
WA7086523Medicaid