Basic Information
Provider Information | |||||||||
NPI: | 1184106437 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEACEHEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST. JOHN MEDICAL CENTER-PEACEHEALTH THERAPY AND WELLNESS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986838004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607291462 | ||||||||
FaxNumber: | 3607293104 | ||||||||
Practice Location | |||||||||
Address1: | TRIANGLE MALL SUITE 16 1015 OCEAN BEACH HWY | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 98632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3605013750 | ||||||||
FaxNumber: | 3605013751 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/04/2018 | ||||||||
LastUpdateDate: | 09/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | METCALF | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | CHARLES | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE PHMG | ||||||||
AuthorizedOfficialTelephone: | 3607291743 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   | WA | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 335E00000X |   | WA | Y |   | Suppliers | Prosthetic/Orthotic Supplier |   |
No ID Information.