Basic Information
| Provider Information | |||||||||
| NPI: | 1356757389 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNATIONAL COMMUNITY HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ICHS CLINIC AT ACRS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3007 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981143007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3639 MARTIN LUTHER KING JR WAY S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981446847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066957600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2014 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAHBAZIAN | ||||||||
| AuthorizedOfficialFirstName: | HERMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2067883618 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 600436519 | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 600436519 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.