Organization
PEACEHEALTH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LORI MCCOY (PROVIDER ENROLLMENT SPECIALIST)
(360) 729-1411
Entity
Organization
Contact information
Practice address
212 CARLANNA LAKE RD, #204, KETCHIKAN, AK 99901-5642
(907) 225-7346
Mailing address
1115 SE 164TH AVE, DEPT 358, VANCOUVER, WA 98683-9324
(360) 729-1411
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
5790
AK
Other
Enumeration date
03/20/2014
Last updated
03/20/2014
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