| NPI | 1023394210 |
|---|---|
| Doing Business As | PROVIDENCE MEDICAL GROUP HAWTHORNE |
| Entity Type | Organization |
| Authorized Contact | KATLYN LEE Credentialing Specialist 509-474-7159 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Enumeration Date | 2011-11-01 |
| Last Update Date | 2011-11-01 |