Provider Demographics
NPI:1245375518
Name:FAMILY MEDICAL CENTER OF FORKS, INC, PS
Entity type:Organization
Organization Name:FAMILY MEDICAL CENTER OF FORKS, INC, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:KRIEBEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-374-6224
Mailing Address - Street 1:PO BOX 455
Mailing Address - Street 2:
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331-0455
Mailing Address - Country:US
Mailing Address - Phone:360-374-6224
Mailing Address - Fax:360-374-6039
Practice Address - Street 1:461 G ST
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331-9025
Practice Address - Country:US
Practice Address - Phone:360-374-6224
Practice Address - Fax:360-374-6039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA13422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7020654Medicaid
WA1770509242OtherLAURA NPI
WA7058829Medicaid
WA1659374114OtherDR K NPI #
WA0048001OtherWA ST L&I
WA8156200Medicaid
WAKR9095OtherREGENCE
WA7020654Medicaid
WA1770509242OtherLAURA NPI
WA7058829Medicaid