Basic Information
Provider Information | |||||||||
NPI: | 1932346764 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEA-MAR COMMUNITY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 34703 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981241703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2067643335 | ||||||||
FaxNumber: | 2067640489 | ||||||||
Practice Location | |||||||||
Address1: | 14434 AMBAUM BLVD SW | ||||||||
Address2: | SUITE 5 | ||||||||
City: | BURIEN | ||||||||
State: | WA | ||||||||
PostalCode: | 981661438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2068126140 | ||||||||
FaxNumber: | 2068126177 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2009 | ||||||||
LastUpdateDate: | 03/30/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RIOJAS | ||||||||
AuthorizedOfficialFirstName: | ROGELIO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2067883226 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 132700000X | 600-537-278-1 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietary Manager |   | 261QF0400X | 600 537 278 1 | WA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.