Provider Demographics
NPI:1710929252
Name:L G STECK MEMORIAL CLINIC P S
Entity Type:Organization
Organization Name:L G STECK MEMORIAL CLINIC P S
Other - Org Name:STECK MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-748-0211
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0260
Mailing Address - Country:US
Mailing Address - Phone:360-748-0211
Mailing Address - Fax:360-748-8732
Practice Address - Street 1:1299 BISHOP RD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-8758
Practice Address - Country:US
Practice Address - Phone:360-748-0211
Practice Address - Fax:360-748-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QM1300X
261QM1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0032700OtherLABOR & INDUSTRIES
WA0568510001OtherDMERC SUPPLIER ID
WA7131733OtherMEDICAID CENTRALIA SPECIA
WA9039751OtherMEDICAID DME
WAC46630OtherRAILROAD MEDICARE
WA02025138OtherMEDICAID CHIROPRACTOR
WA7131725OtherMEDICAID L G STECK MEMORI
WA7069883Medicaid
WA7074131OtherMEDICAID NAPAVINE MEDICAL
WA7098767OtherMEDICAID AUDIOLOGY
WA7069883Medicaid
WA503901Medicare PIN
G115122300Medicare PIN
WAC46630OtherRAILROAD MEDICARE