Healthcare Provider Details

I. General information

NPI: 1558448175
Provider Name (Legal Business Name): MUCKLESHOOT INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17500 SE 392ND ST
AUBURN WA
98092-9705
US

IV. Provider business mailing address

17500 SE 392ND ST
AUBURN WA
98092-9705
US

V. Phone/Fax

Practice location:
  • Phone: 253-939-6648
  • Fax: 253-887-8737
Mailing address:
  • Phone: 253-939-6648
  • Fax: 253-887-8737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHLEEN GOODWIN-SNYDER
Title or Position: HEALTH MANAGER
Credential:
Phone: 253-939-6648