Healthcare Provider Details

I. General information

NPI: 1467905695
Provider Name (Legal Business Name): PACIFIC ISLAMIC COMMUNITY AND CULTURAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2016
Last Update Date: 07/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10634 E RIVERSIDE DR SUITE 300
BOTHELL WA
98011-3757
US

IV. Provider business mailing address

10634 E RIVERSIDE DR SUITE 300
BOTHELL WA
98011-3757
US

V. Phone/Fax

Practice location:
  • Phone: 425-412-6318
  • Fax:
Mailing address:
  • Phone: 425-412-6318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number200385
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. SYED JAMAL MUSTAFA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 425-806-5021