Provider Demographics
NPI:1205151388
Name:LOWER ELWHA MATERNAL SUPPORT SERVICES
Entity type:Organization
Organization Name:LOWER ELWHA MATERNAL SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL & HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:MCEACHRANE-GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-452-6252
Mailing Address - Street 1:243511 W HIGHWAY 101
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-9472
Mailing Address - Country:US
Mailing Address - Phone:360-452-6252
Mailing Address - Fax:360-452-6274
Practice Address - Street 1:243511 W HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98363-9472
Practice Address - Country:US
Practice Address - Phone:360-452-6252
Practice Address - Fax:360-452-6274
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOWER ELWHA KLALLAM TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-01
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7402480Medicaid