Basic Information
| Provider Information | |||||||||
| NPI: | 1194859785 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF WASHINGTON | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH REGAL HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34584 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092417349 | ||||||||
| FaxNumber: | 5092417628 | ||||||||
| Practice Location | |||||||||
| Address1: | 4102 S REGAL ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992237737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095352277 | ||||||||
| FaxNumber: | 5094343182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEERY | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2066301818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GROUP HEALTH COOPERATIVE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | CF00003595 | WA | N | Suppliers | Pharmacy | Clinic Pharmacy | 333600000X | CF00003595 | WA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4923985 | 01 | WA | NCPDP | OTHER |