Provider Demographics
NPI:1609018076
Name:MEMORIAL PRACTICE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MEMORIAL PRACTICE MANAGEMENT, LLC
Other - Org Name:PACIFIC CREST FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
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 1:311 S 72ND AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-1661
Practice Address - Country:US
Practice Address - Phone:509-972-1818
Practice Address - Fax:509-972-7842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7091168Medicaid
WA7091168Medicaid
WAGAB33634Medicare PIN