Provider Demographics
NPI:1619086766
Name:GRANT COUNTY PUBLIC HOSPITAL DISTRICT 1
Entity Type:Organization
Organization Name:GRANT COUNTY PUBLIC HOSPITAL DISTRICT 1
Other - Org Name:SAMARITAN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-793-9710
Mailing Address - Street 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:509-793-9715
Mailing Address - Fax:509-764-3244
Practice Address - Street 1:1550 S PIONEER WAY STE 115
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4618
Practice Address - Country:US
Practice Address - Phone:509-793-9713
Practice Address - Fax:509-764-3244
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAMARITAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-30
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1014658Medicaid
WA7063415Medicaid
WA7109929Medicaid
WA7109929Medicaid
WA7063415Medicaid