Provider Demographics
NPI:1588623581
Name:L KEITH HANSON PLLC
Entity Type:Organization
Organization Name:L KEITH HANSON PLLC
Other - Org Name:COMMUNITY MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-689-2525
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812-0337
Mailing Address - Country:US
Mailing Address - Phone:509-689-2525
Mailing Address - Fax:509-689-3247
Practice Address - Street 1:520 W INDIAN AVE
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812
Practice Address - Country:US
Practice Address - Phone:509-689-2525
Practice Address - Fax:509-689-3247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207V00000X, 208000000X
WA503894261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7124779Medicaid
WAGAB36675Medicare PIN
WA7124779Medicaid