Basic Information
| Provider Information | |||||||||
| NPI: | 1902983109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNATIONAL COMMUNITY HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOLLY PARK MEDICAL & DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3007 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981143007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067883600 | ||||||||
| FaxNumber: | 2066525216 | ||||||||
| Practice Location | |||||||||
| Address1: | 3815 S OTHELLO ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981183510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067883500 | ||||||||
| FaxNumber: | 2067883521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAHBAZIAN | ||||||||
| AuthorizedOfficialFirstName: | HERMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2067883618 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTERNATIONAL COMMUNITY HEALTH SERVICES | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 600436519 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 251B00000X | N | Agencies | Case Management | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 7125289 | 05 | WA | MEDICAID |