Healthcare Provider Details

I. General information

NPI: 1760428650
Provider Name (Legal Business Name): PORT GAMBLE S'KLALLAM TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32014 LITTLE BOSTON RD NE
KINGSTON WA
98346-9734
US

IV. Provider business mailing address

32014 LITTLE BOSTON RD NE
KINGSTON WA
98346-9734
US

V. Phone/Fax

Practice location:
  • Phone: 360-297-9601
  • Fax: 360-297-9614
Mailing address:
  • Phone: 360-297-9601
  • Fax: 360-297-9614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DALLAS I DEGUIRE
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 360-297-9601