Provider Demographics
NPI:1609322528
Name:PROVIDENCE HEALTH & SERVICES
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES
Other - Org Name:D/B/A/ PROVIDENCE DOMINICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SISCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-935-4925
Mailing Address - Street 1:PO BOX 1070
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109-1070
Mailing Address - Country:US
Mailing Address - Phone:509-935-4925
Mailing Address - Fax:509-935-4082
Practice Address - Street 1:110 S. THIRD STREET E.
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109
Practice Address - Country:US
Practice Address - Phone:509-935-4925
Practice Address - Fax:509-935-4082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIHS.FS.60259664253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care