Provider Demographics
NPI:1952386369
Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Other - Org Name:PROVIDENCE MOUNT ST VINCENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR REIMB REG STRAT/ASST SEC ENROLL
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:4831 35TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-2709
Mailing Address - Country:US
Mailing Address - Phone:206-937-3700
Mailing Address - Fax:206-938-8999
Practice Address - Street 1:4831 35TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-2709
Practice Address - Country:US
Practice Address - Phone:206-937-3700
Practice Address - Fax:206-938-8999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-08
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABH-198310400000X
WA77314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA41-07702Medicaid
WA41-07702Medicaid