Provider Demographics
NPI:1639113830
Name:LINCOLN COUNTY HOSPITAL DISTRICT 3
Entity Type:Organization
Organization Name:LINCOLN COUNTY HOSPITAL DISTRICT 3
Other - Org Name:NORTH BASIN MEDICAL CLINICS--REARDAN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:E
Authorized Official - Last Name:LACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-725-7101
Mailing Address - Street 1:10 NICHOLLS ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99122-9729
Mailing Address - Country:US
Mailing Address - Phone:509-725-7501
Mailing Address - Fax:509-725-7504
Practice Address - Street 1:550 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:REARDAN
Practice Address - State:WA
Practice Address - Zip Code:99029
Practice Address - Country:US
Practice Address - Phone:509-796-2737
Practice Address - Fax:509-796-2738
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LINCOLN COUNTY HOSPITAL DISTRICT #3
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-16
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-137207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7101132Medicaid
WACJ6525OtherMEDICARE RAILROAD
WA7117450Medicaid
WAGAB16799Medicare PIN
WA508528Medicare Oscar/Certification
WACJ6525OtherMEDICARE RAILROAD