Provider Demographics
NPI:1750465365
Name:SOUTH BEND CLINIC DBA RIVERVIEW HEALTH CENTER
Entity Type:Organization
Organization Name:SOUTH BEND CLINIC DBA RIVERVIEW HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/CORPORATE SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDI
Authorized Official - Middle Name:R
Authorized Official - Last Name:VAIL-LUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-942-4562
Mailing Address - Street 1:PO BOX 666
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98577-0666
Mailing Address - Country:US
Mailing Address - Phone:360-942-3040
Mailing Address - Fax:360-942-3955
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-3016
Practice Address - Country:US
Practice Address - Phone:360-942-3040
Practice Address - Fax:360-942-3955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00000626207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7840408Medicaid
WA7086515Medicaid
WAGAB11020Medicare PIN
E20254Medicare UPIN
WA7840408Medicaid