Basic Information
Provider Information | |||||||||
NPI: | 1649602756 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8609 EVERGREEN WAY | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982082619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4257893700 | ||||||||
FaxNumber: | 4257893754 | ||||||||
Practice Location | |||||||||
Address1: | 326 S STILLAGUAMISH AVE | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON | ||||||||
State: | WA | ||||||||
PostalCode: | 982231652 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3605725400 | ||||||||
FaxNumber: | 3605725401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2013 | ||||||||
LastUpdateDate: | 03/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FARRELL | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4257893717 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1017523 | 05 | WA |   | MEDICAID | 1730136367 | 01 |   | ORGANIZATION NPI | OTHER |