Provider Demographics
NPI:1881631646
Name:PROVIDENCE HEALTH CARE
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HARGIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-685-6023
Mailing Address - Street 1:982 E COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-3316
Mailing Address - Country:US
Mailing Address - Phone:509-684-2561
Mailing Address - Fax:509-685-2492
Practice Address - Street 1:982 E COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-3316
Practice Address - Country:US
Practice Address - Phone:509-684-2561
Practice Address - Fax:509-685-2492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7027428Medicaid
WAG8867053OtherMEDICARE
WA7300643Medicaid
WA3007630Medicaid
WA9638982Medicaid
WA3007630Medicaid