Provider Demographics
NPI:1639268469
Name:VANCOUVER ENT AND ENT OF THE NORTHWEST PLLC
Entity Type:Organization
Organization Name:VANCOUVER ENT AND ENT OF THE NORTHWEST PLLC
Other - Org Name:VANCOUVER EAR, NOSE & THROAT HEAD & NECK SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-449-6612
Mailing Address - Street 1:1405 SE 164TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9644
Mailing Address - Country:US
Mailing Address - Phone:360-256-4425
Mailing Address - Fax:360-260-7249
Practice Address - Street 1:14411 NE 20TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-6432
Practice Address - Country:US
Practice Address - Phone:360-256-4425
Practice Address - Fax:360-260-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7135502Medicaid
WA204729OtherWA DEPT OF L&I
WA8940474OtherWA CRIME VICTIMS
WA204729OtherWA DEPT OF L&I