Provider Demographics
NPI:1659505840
Name:OUR LADY OF LOURDES HEALTH CENTER
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES HEALTH CENTER
Other - Org Name:LOURDES WEST PASCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-543-2483
Mailing Address - Street 1:7425 WRIGLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301
Mailing Address - Country:US
Mailing Address - Phone:509-545-6220
Mailing Address - Fax:509-545-6842
Practice Address - Street 1:7425 WRIGLEY DRIVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301
Practice Address - Country:US
Practice Address - Phone:509-545-6220
Practice Address - Fax:509-545-6842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA113003371207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA501337Medicare Oscar/Certification