Provider Demographics
NPI:1790954907
Name:DAVID C WYNECOOP MEMORIAL CLINIC DHHS IHS WELLPINIT SERVICE UNIT
Entity Type:Organization
Organization Name:DAVID C WYNECOOP MEMORIAL CLINIC DHHS IHS WELLPINIT SERVICE UNIT
Other - Org Name:WELLPINIT SERVICE UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:TOINEETA-FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-258-4517
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:WELLPINIT
Mailing Address - State:WA
Mailing Address - Zip Code:99040-0357
Mailing Address - Country:US
Mailing Address - Phone:509-258-4517
Mailing Address - Fax:509-258-7152
Practice Address - Street 1:6203 AGENCY LOOP RD
Practice Address - Street 2:
Practice Address - City:WELLPINIT
Practice Address - State:WA
Practice Address - Zip Code:99040-0357
Practice Address - Country:US
Practice Address - Phone:509-258-4517
Practice Address - Fax:509-258-7152
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHHS INDIAN HEALTH SERVICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7100407Medicaid
WA7100407Medicaid