Provider Demographics
NPI:1760466114
Name:WALLA WALLA GENERAL HOSPITAL
Entity Type:Organization
Organization Name:WALLA WALLA GENERAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOCKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-0480
Mailing Address - Street 1:PO BOX 1398
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0309
Mailing Address - Country:US
Mailing Address - Phone:509-525-0480
Mailing Address - Fax:509-527-8159
Practice Address - Street 1:1025 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4116
Practice Address - Country:US
Practice Address - Phone:509-525-0480
Practice Address - Fax:509-527-8159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
WAHAC.FS.00000043282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR208850Medicaid
WA1018337Medicaid
OR208850Medicaid
WAG001346700Medicare PIN