Provider Demographics
NPI:1548402167
Name:MEMORIAL PRACTICE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MEMORIAL PRACTICE MANAGEMENT, LLC
Other - Org Name:SELAH FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:W
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-248-7849
Mailing Address - Street 1:PO BOX 2947
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-2947
Mailing Address - Country:US
Mailing Address - Phone:509-248-7849
Mailing Address - Fax:509-248-8291
Practice Address - Street 1:202 W NACHES AVE
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-1326
Practice Address - Country:US
Practice Address - Phone:509-697-5511
Practice Address - Fax:509-697-9313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty