Provider Demographics
NPI:1881858140
Name:PUBLIC HOSPITAL DISTRICT 3 OF PACIFIC COUNTY
Entity Type:Organization
Organization Name:PUBLIC HOSPITAL DISTRICT 3 OF PACIFIC COUNTY
Other - Org Name:NASELLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-642-3181
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:21 NORTH VALLEY ROAD
Mailing Address - City:NASELLE
Mailing Address - State:WA
Mailing Address - Zip Code:98638-0188
Mailing Address - Country:US
Mailing Address - Phone:360-484-7161
Mailing Address - Fax:360-484-7178
Practice Address - Street 1:309 KNAPPTON RD
Practice Address - Street 2:
Practice Address - City:NASELLE
Practice Address - State:WA
Practice Address - Zip Code:98638-8632
Practice Address - Country:US
Practice Address - Phone:360-484-7161
Practice Address - Fax:360-484-7181
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUBLIC HOSPITAL DISTRICT 3 OF PACIFIC COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-16
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHAC.FS.00000079261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA503984Medicare Oscar/Certification