Basic Information
| Provider Information | |||||||||
| NPI: | 1669047098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEATTLE INDIAN HEALTH BOARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 12TH AVE S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063249360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12736 33RD AVE NE # 200 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981254504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063249360 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2021 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | LAFONTAINE | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2063244036 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SEATTLE INDIAN HEALTH BOARD | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.