Provider Demographics
NPI:1962664003
Name:L. G. STECK MEMORIAL CLINIC, P. S.
Entity Type:Organization
Organization Name:L. G. STECK MEMORIAL CLINIC, P. S.
Other - Org Name:CENTRALIA SPECIALTY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECERATARY
Authorized Official - Prefix:MR
Authorized Official - First Name:HARLEY
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-748-0211
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0260
Mailing Address - Country:US
Mailing Address - Phone:360-736-1965
Mailing Address - Fax:360-736-2539
Practice Address - Street 1:1707 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9071
Practice Address - Country:US
Practice Address - Phone:360-736-1965
Practice Address - Fax:360-736-2539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7131733Medicaid
503900Medicare Oscar/Certification