Healthcare Provider Details

I. General information

NPI: 1023677523
Provider Name (Legal Business Name): SKOOKUM EDUCATIONAL PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 AUTO CENTER WAY
BREMERTON WA
98312-4312
US

IV. Provider business mailing address

PO BOX 5359
BREMERTON WA
98312-0518
US

V. Phone/Fax

Practice location:
  • Phone: 360-475-0756
  • Fax: 360-475-0757
Mailing address:
  • Phone: 360-475-0756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: RYAN WIESE
Title or Position: CONTRACTS MANAGER
Credential:
Phone: 360-475-0756