Provider Demographics
NPI:1538213616
Name:OUR LADY OF LOURDES HEALTH CENTER
Entity type:Organization
Organization Name:OUR LADY OF LOURDES HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-543-2483
Mailing Address - Street 1:PO BOX 1260
Mailing Address - Street 2:
Mailing Address - City:CONNELL
Mailing Address - State:WA
Mailing Address - Zip Code:99326-1260
Mailing Address - Country:US
Mailing Address - Phone:509-234-3410
Mailing Address - Fax:509-543-2488
Practice Address - Street 1:650 S COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326
Practice Address - Country:US
Practice Address - Phone:509-234-3410
Practice Address - Fax:509-543-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA113003371261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG319211600Medicare PIN