Provider Demographics
NPI:1932238136
Name:YAKIMA VALLEY FARM WORKERS CLINIC
Entity Type:Organization
Organization Name:YAKIMA VALLEY FARM WORKERS CLINIC
Other - Org Name:CHILDRENS VILLAGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:OLIVARES
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:509-865-6175
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-574-3200
Mailing Address - Fax:
Practice Address - Street 1:3801 KERN WAY
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6340
Practice Address - Country:US
Practice Address - Phone:509-574-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YAKIMA VALLEY FARM WORKERS CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-05
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5027214Medicaid