MEDICARE: THUNDERBIRD TREATMENT CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	0024817002 BLSEATTLE	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	005701	OTHER	WA	TARGET
2	051276747	OTHER	WA	ALCOHOL AND SUBSTACE ABUS

General Provider Information

NPI Number	:	1215002365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THUNDERBIRD TREATMENT CENTER, LLC

Provider Business Mailing Address
First Line	:	611 12TH AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98144-2007
Country	:	US
Telephone Number	:	206-324-9360
Fax Number	:	206-324-8910

Provider Business Practice Location Address
First Line	:	12736 33RD AVE NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-4504
Country	:	US
Telephone Number	:	206-324-9360
Fax Number	:	206-324-8910

Authorized Official
Title or Position	:	REVENUE CYCLE MANAGER
Name	:	ANGELA LAFONTAINE
Credential	:
Telephone Number	:	206-324-9360

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	04/14/2026

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