Basic Information
| Provider Information | |||||||||
| NPI: | 1295307569 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEA - MAR COMMUNITY HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 34703 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256164100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4111 ALDERWOOD MALL BLVD | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980366765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256164100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2021 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ESPINOSA | ||||||||
| AuthorizedOfficialFirstName: | OMAR | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2536816610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0050X | N | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.