Basic Information
| Provider Information | |||||||||
| NPI: | 1326186370 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEATTLE INDIAN HEALTH BOARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3364 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981143364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063249360 | ||||||||
| FaxNumber: | 2063248910 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 12TH AVE S | ||||||||
| Address2: | 200 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981441910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063249360 | ||||||||
| FaxNumber: | 2063248910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | LUCERO | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2063249360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MPP | ||||||||
| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 600440936 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 50D0065434 | 01 | WA | CLIA LAB | OTHER |