Provider Demographics
NPI:1750434098
Name:PROVIDENCE HEALTH SYSTEM OF WASHINGTON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM OF WASHINGTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-330-8541
Mailing Address - Street 1:914 S SCHEUBER RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9027
Mailing Address - Country:US
Mailing Address - Phone:360-330-8815
Mailing Address - Fax:360-330-8812
Practice Address - Street 1:500 SE WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3058
Practice Address - Country:US
Practice Address - Phone:360-740-6542
Practice Address - Fax:360-740-8367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility