Provider Demographics
NPI:1881681518
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE ELDERPLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:206-320-5325
Mailing Address - Street 1:2001 LIND AVE SW
Mailing Address - Street 2:SUITE 160
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3303
Mailing Address - Country:US
Mailing Address - Phone:206-320-5325
Mailing Address - Fax:206-760-6339
Practice Address - Street 1:4515 MARTIN LUTHER KING JR WAY S
Practice Address - Street 2:SUITE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-2182
Practice Address - Country:US
Practice Address - Phone:206-320-5325
Practice Address - Fax:206-760-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH5007Medicare ID - Type Unspecified