Basic Information
| Provider Information | |||||||||
| NPI: | 1962754713 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEIGHBORCARE HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEIGHBORCARE HEALTH AT LAKE CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 12TH AVE SOUTH | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065483114 | ||||||||
| FaxNumber: | 2067626355 | ||||||||
| Practice Location | |||||||||
| Address1: | 12721 30TH AVE NE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981254498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064170326 | ||||||||
| FaxNumber: | 2064170783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 01/12/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERIKSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2064616935 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| 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 | 501965 | 01 | WA | CMS CERTIFICATION | OTHER |