Basic Information
| Provider Information | |||||||||
| NPI: | 1134632599 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SWINOMISH HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIDGWALIC WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8212 S MARCH POINT RD | ||||||||
| Address2: | |||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982218684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605882805 | ||||||||
| FaxNumber: | 3605882808 | ||||||||
| Practice Location | |||||||||
| Address1: | 8212 S MARCH POINT RD | ||||||||
| Address2: | |||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982218684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605882805 | ||||||||
| FaxNumber: | 3605882808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2017 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEYES | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER - INTERIM | ||||||||
| AuthorizedOfficialTelephone: | 3605882800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SWINOMISH INDIAN TRIBAL COMMUNITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 2083P0901X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 261QM2800X | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 208D00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 2091872 | 05 | WA | MEDICAID |