Basic Information
| Provider Information | |||||||||
| NPI: | 1013049741 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY LYNNWOOD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 13060 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982063060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257893700 | ||||||||
| FaxNumber: | 4257893750 | ||||||||
| Practice Location | |||||||||
| Address1: | 4111 194TH ST SW STE 100 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258355200 | ||||||||
| FaxNumber: | 4258355201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 09/22/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4257893700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 7034036 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | 7034036 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 7034036 | 05 | WA | MEDICAID | 32770 | 01 | WA | WORKMAN COMPENSATION | OTHER | 8934243 | 01 | WA | CRIME VICTIM COMPENSATION | OTHER |