Provider Demographics
NPI:1649394800
Name:WHITE RIVER FAMILY CARE LLC
Entity Type:Organization
Organization Name:WHITE RIVER FAMILY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:KRUIZENGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-829-0625
Mailing Address - Street 1:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98321
Mailing Address - Country:US
Mailing Address - Phone:360-829-0625
Mailing Address - Fax:360-829-9860
Practice Address - Street 1:305 N.RIVER AVE.
Practice Address - Street 2:
Practice Address - City:BUCKLEY
Practice Address - State:WA
Practice Address - Zip Code:98321
Practice Address - Country:US
Practice Address - Phone:360-829-0625
Practice Address - Fax:360-829-9860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB33939Medicare PIN