MEDICARE: HOODSPORT FAMILY CLINIC,P.S.

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	261Q00000X	Clinic/Center	S71181	WA
2	261QR1300X	Rural Health Clinic/Center	503884	WA

General Provider Information

NPI Number	:	1457359788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOODSPORT FAMILY CLINIC,P.S.

Provider Business Mailing Address
First Line	:	PO BOX 279
Second Line	:
City	:	HOODSPORT
State	:	WA
Zip	:	98548-0279
Country	:	US
Telephone Number	:	360-877-0372
Fax Number	:	360-877-0565

Provider Business Practice Location Address
First Line	:	24261 NORTH US HIGHWAY 101
Second Line	:
City	:	HOODSPORT
State	:	WA
Zip	:	98548-0279
Country	:	US
Telephone Number	:	360-877-0372
Fax Number	:	360-877-0565

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. DAVID LEE MOORE
Credential	:
Telephone Number	:	360-877-0372

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	12/09/2010

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