Provider Demographics
NPI:1689638553
Name:INTERLOCAL ORGANIZATION OF LC RURAL
Entity Type:Organization
Organization Name:INTERLOCAL ORGANIZATION OF LC RURAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILTBANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-864-2366
Mailing Address - Street 1:PO BOX 3510
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-3510
Mailing Address - Country:US
Mailing Address - Phone:360-394-7030
Mailing Address - Fax:360-394-7097
Practice Address - Street 1:150 N 2ND ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:WA
Practice Address - Zip Code:98591
Practice Address - Country:US
Practice Address - Phone:360-864-2366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA21D023416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0235205OtherL&I AND CRIME VICTIMS
WA9038480Medicaid
WAIN9964OtherREGENCE
OR182534Medicaid
G115000292Medicare PIN
WAIN9964OtherREGENCE