Provider Demographics
NPI:1821240425
Name:PROVIDENCE HEALTH & SERVICES - WA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WA
Other - Org Name:PROVIDENCE ADULT DAY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY OF ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:6018 N ASTOR ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-1107
Mailing Address - Country:US
Mailing Address - Phone:509-482-2475
Mailing Address - Fax:509-482-2490
Practice Address - Street 1:6018 N ASTOR ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1107
Practice Address - Country:US
Practice Address - Phone:509-482-2475
Practice Address - Fax:509-482-2490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1027809Medicaid
WA425223Medicaid