Provider Demographics
NPI:1811025216
Name:GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
Entity Type:Organization
Organization Name:GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
Other - Org Name:SUMMIT PACIFIC WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-495-3244
Mailing Address - Street 1:600 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9560
Mailing Address - Country:US
Mailing Address - Phone:360-346-2222
Mailing Address - Fax:360-346-2163
Practice Address - Street 1:610 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541-9551
Practice Address - Country:US
Practice Address - Phone:360-346-2222
Practice Address - Fax:360-346-2163
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-28
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
WAHAC.FS.00000186261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7103815Medicaid
WAAB18052Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
WAG000800088Medicare UPIN
WA508556Medicare Oscar/Certification