Basic Information
| Provider Information | |||||||||
| NPI: | 1710253109 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY SALMON CREEK HOSPITAL | ||||||||
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| OtherOrganizationName: | LEGACY SALMON CREEK PEDIATRIC REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972082077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 NE 139TH ST. | ||||||||
| Address2: | MOB A, STE 200 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604871777 | ||||||||
| FaxNumber: | 3604871779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPPORT | ||||||||
| AuthorizedOfficialTelephone: | 5034135092 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SI60230943 / INTERIM | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.