Provider Demographics
NPI:1033101191
Name:CITY OF MONTESANO
Entity type:Organization
Organization Name:CITY OF MONTESANO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPUTY CLERK
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WISDOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-249-4851
Mailing Address - Street 1:112 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-3707
Mailing Address - Country:US
Mailing Address - Phone:360-249-4851
Mailing Address - Fax:360-249-4971
Practice Address - Street 1:310 E PIONEER AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-4602
Practice Address - Country:US
Practice Address - Phone:360-249-4851
Practice Address - Fax:360-249-4971
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF MONTESANO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-16
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA14M063416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9279803Medicaid
WAG000800027Medicare ID - Type UnspecifiedPROVIDER #