Provider Demographics
NPI:1295997591
Name:COLVILLE MEDICAL CENTER PS
Entity type:Organization
Organization Name:COLVILLE MEDICAL CENTER PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:REHN
Authorized Official - Suffix:
Authorized Official - Credentials:DHA, MPA, CMPE
Authorized Official - Phone:509-684-3701
Mailing Address - Street 1:1200 E COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-3354
Mailing Address - Country:US
Mailing Address - Phone:509-684-3701
Mailing Address - Fax:509-684-5817
Practice Address - Street 1:1200 E COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-3354
Practice Address - Country:US
Practice Address - Phone:509-684-3701
Practice Address - Fax:509-684-5817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
WA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7108749Medicaid
WA7108749Medicaid