Provider Demographics
NPI:1720276207
Name:RICHARD L. DICKSON
Entity Type:Organization
Organization Name:RICHARD L. DICKSON
Other - Org Name:SOL DUC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-374-6642
Mailing Address - Street 1:PO BOX 1918
Mailing Address - Street 2:
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331
Mailing Address - Country:US
Mailing Address - Phone:360-374-6642
Mailing Address - Fax:360-374-5335
Practice Address - Street 1:481 WEST E ST
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331
Practice Address - Country:US
Practice Address - Phone:360-374-6642
Practice Address - Fax:360-374-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7079999Medicaid
WA59570OtherDEPT OF L I
WA503840Medicare Oscar/Certification
WA59570OtherDEPT OF L I
WAA14710Medicare UPIN