Provider Demographics
NPI:1356393383
Name:YAKIMA VALLEY PROFESSIONAL SERVICES ON 12TH, PC
Entity type:Organization
Organization Name:YAKIMA VALLEY PROFESSIONAL SERVICES ON 12TH, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-248-7849
Mailing Address - Street 1:PO BOX 2947
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-2947
Mailing Address - Country:US
Mailing Address - Phone:509-248-7849
Mailing Address - Fax:509-249-5042
Practice Address - Street 1:402 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3115
Practice Address - Country:US
Practice Address - Phone:509-248-3263
Practice Address - Fax:509-573-3818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7056922Medicaid
WAGAB33627Medicare PIN
WAG8866567Medicare PIN
WA7056922Medicaid
WACK6236Medicare PIN