Provider Demographics
NPI:1013750082
Name:CHERRY HEIGHTS FAMILY MEDICINE OF WASHINGTON
Entity type:Organization
Organization Name:CHERRY HEIGHTS FAMILY MEDICINE OF WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-985-2260
Mailing Address - Street 1:1560 N CRESTMONT DR STE A
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2178
Mailing Address - Country:US
Mailing Address - Phone:208-650-4888
Mailing Address - Fax:
Practice Address - Street 1:1861 CLARET LOOP NW
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-8380
Practice Address - Country:US
Practice Address - Phone:208-650-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-17
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty