Basic Information
| Provider Information | |||||||||
| NPI: | 1659739373 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEIGHBORCARE HEALTH | ||||||||
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| OtherOrganizationName: | BALLARD HOMELESS DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 12TH AVE S | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065483102 | ||||||||
| FaxNumber: | 2067626355 | ||||||||
| Practice Location | |||||||||
| Address1: | 1753 NW 56TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981075279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067825939 | ||||||||
| FaxNumber: | 2067825934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2016 | ||||||||
| LastUpdateDate: | 02/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | CHILDS | ||||||||
| AuthorizedOfficialFirstName: | JANINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2065483034 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.