Provider Demographics
NPI:1790703106
Name:COUNTRY CLINIC
Entity Type:Organization
Organization Name:COUNTRY CLINIC
Other - Org Name:THE WINTHROP COUNTRY CLINIC LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-996-8180
Mailing Address - Street 1:PO BOX 945
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:WA
Mailing Address - Zip Code:98862-0945
Mailing Address - Country:US
Mailing Address - Phone:509-996-8180
Mailing Address - Fax:509-996-3374
Practice Address - Street 1:1116 HWY 20
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:WA
Practice Address - Zip Code:98862
Practice Address - Country:US
Practice Address - Phone:509-996-8180
Practice Address - Fax:509-996-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7103807Medicaid
WA7103807Medicaid
WA=========OtherIRS NUMBER