Provider Demographics
NPI:1609483429
Name:THE VANCOUVER CLINIC INC PS
Entity Type:Organization
Organization Name:THE VANCOUVER CLINIC INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-397-3352
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4896
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:4500 SE COLUMBIA PALISADES DR
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-8444
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1780
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE VANCOUVER CLINIC INC PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1046502Medicaid