Provider Demographics
NPI:1710054499
Name:WHITE CROSS ORTHOPEDIC
Entity Type:Organization
Organization Name:WHITE CROSS ORTHOPEDIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARDELLA
Authorized Official - Middle Name:O
Authorized Official - Last Name:MYHRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-423-6027
Mailing Address - Street 1:811 11TH AVE
Mailing Address - Street 2:STE A
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2462
Mailing Address - Country:US
Mailing Address - Phone:360-423-6027
Mailing Address - Fax:360-501-4454
Practice Address - Street 1:811 11TH AVE
Practice Address - Street 2:STE A
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2462
Practice Address - Country:US
Practice Address - Phone:360-423-6027
Practice Address - Fax:360-501-4454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9048174Medicaid
WA9014671Medicaid
WA9006206Medicaid
WA0229680001Medicare NSC