Provider Demographics
NPI:1558512368
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE ST MARY HOME HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:AVP REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 84812
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6112
Mailing Address - Country:US
Mailing Address - Phone:509-897-8600
Mailing Address - Fax:
Practice Address - Street 1:380 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2924
Practice Address - Country:US
Practice Address - Phone:509-897-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIS446251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9109703Medicaid
WA074073OtherL&I
WA507034Medicare PIN