Provider Demographics
NPI:1639287188
Name:PEDIATRIC CLINIC, INC., P.S.
Entity Type:Organization
Organization Name:PEDIATRIC CLINIC, INC., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STRANDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-425-6117
Mailing Address - Street 1:784 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2315
Mailing Address - Country:US
Mailing Address - Phone:360-425-6117
Mailing Address - Fax:360-425-8557
Practice Address - Street 1:784 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2315
Practice Address - Country:US
Practice Address - Phone:360-425-6117
Practice Address - Fax:360-636-1297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600024847261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7851702Medicaid
WAAB15232Medicare ID - Type UnspecifiedMEDICARE