Provider Demographics
NPI:1952687386
Name:PROVIDENCE PHSYICIAN SERVICES
Entity Type:Organization
Organization Name:PROVIDENCE PHSYICIAN SERVICES
Other - Org Name:PROVIDENCE FAMILY MEDICINE MANITO CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED. SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-6798
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1919 S. GRAND BLVD.
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203
Practice Address - Country:US
Practice Address - Phone:509-789-9925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PHSYICIAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty