Provider Demographics
NPI:1396990701
Name:PEACEHEALTH
Entity type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-788-6797
Mailing Address - Street 1:2901 SQUALICUM PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225
Mailing Address - Country:US
Mailing Address - Phone:360-729-1411
Mailing Address - Fax:360-501-7535
Practice Address - Street 1:4545 CORDATA PARKWAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7123
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEACEHEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-26
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-145261QE0800X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7146814Medicaid
WA7146814Medicaid