Provider Demographics
NPI:1982761904
Name:PACIFIC COUNTY HOSPITAL DISTRICT #2
Entity Type:Organization
Organization Name:PACIFIC COUNTY HOSPITAL DISTRICT #2
Other - Org Name:SOUTHBEND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-875-4508
Mailing Address - Street 1:PO BOX 1370
Mailing Address - Street 2:800 ALDER STREET
Mailing Address - City:SOUTHBEND
Mailing Address - State:WA
Mailing Address - Zip Code:98586
Mailing Address - Country:US
Mailing Address - Phone:360-875-5339
Mailing Address - Fax:360-875-6167
Practice Address - Street 1:800 ALDER STREET
Practice Address - Street 2:
Practice Address - City:SOUTHBEND
Practice Address - State:WA
Practice Address - Zip Code:98586
Practice Address - Country:US
Practice Address - Phone:360-875-5339
Practice Address - Fax:360-875-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7102957Medicaid
WAAB18454Medicare ID - Type Unspecified