Provider Demographics
NPI:1760411912
Name:YAKIMA VALLEY PROFESSIONAL SERVICES ON TIETON, PC
Entity Type:Organization
Organization Name:YAKIMA VALLEY PROFESSIONAL SERVICES ON TIETON, PC
Other - Org Name:PACIFIC CREST FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-248-7849
Mailing Address - Street 1:PO BOX 2947
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-2947
Mailing Address - Country:US
Mailing Address - Phone:509-248-7849
Mailing Address - Fax:509-249-5042
Practice Address - Street 1:311 S. 72ND AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908
Practice Address - Country:US
Practice Address - Phone:509-972-1818
Practice Address - Fax:509-972-7842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027321261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7091168Medicaid
WACK6331Medicare PIN
WA7091168Medicaid