Basic Information
| Provider Information | |||||||||
| NPI: | 1538225826 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEIGHBORCARE HEALTH | ||||||||
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| OtherOrganizationName: | PUGET SOUND NEIGHBORHOOD HEALTH CENTERS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 SPRUCE ST | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064616935 | ||||||||
| FaxNumber: | 2064618382 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 POST ALLEY | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981011015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067284143 | ||||||||
| FaxNumber: | 2069564018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 11/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | SECORD | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | LLOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2064616935 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | F000058312 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 6001384186 | 01 | STATE TAX ID | OTHER | 4914493 | 01 | NCPDP | OTHER | 6008965 | 05 | WA | MEDICAID |