# MARYS CORNER MEDICAL CLINIC INC PS

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Marys Corner Medical Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1194973628
- **Authorized official:** MISS KIMBERLY HOPE INGLIS (OFFICE MANAGER)
- **Authorized official phone:** (360) 262-3966

## Contact information

- **Practice address:** 4254 JACKSON HWY, CHEHALIS, WA 98532
- **Practice address phone:** (360) 262-3966
- **Practice address fax:** (360) 262-3967
- **Mailing address:** 4254 JACKSON HWY., CHEHALIS, WA 98532
- **Mailing address phone:** (360) 262-3966
- **Mailing address fax:** (360) 262-3967

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | MD00039760 | WA | — |
| 207Q00000X | Family Medicine Physician | OP00000823 | WA | Yes |
| 261QR1300X | Rural Health Clinic/Center | AP30005675 | WA | — |
| 261QR1300X | Rural Health Clinic/Center | MD00039760 | WA | — |
| 261QR1300X | Rural Health Clinic/Center | OP00000823 | WA | — |
| 261QR1300X | Rural Health Clinic/Center | PA0004588 | WA | — |
| 363AM0700X | Medical Physician Assistant | PA10004588 | WA | — |
| 363LF0000X | Family Nurse Practitioner | AP30005675 | WA | — |

## Other

- **Enumeration date:** 09/09/2008
- **Last updated:** 04/30/2012