Basic Information
| Provider Information | |||||||||
| NPI: | 1457497497 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEA-MAR COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34703 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067643335 | ||||||||
| FaxNumber: | 2067640489 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N LAVENTURE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982732766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604284075 | ||||||||
| FaxNumber: | 3604285813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 11/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | WOODLAND | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2536816601 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QF0400X | 6005372781 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 7406069 | 05 | WA | MEDICAID |