Healthcare Provider Details

I. General information

NPI: 1164483285
Provider Name (Legal Business Name): SWINOMISH INDIAN TRIBAL COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17400 RESERVATION RD
LA CONNER WA
98257-8801
US

IV. Provider business mailing address

PO BOX 683
LA CONNER WA
98257-0683
US

V. Phone/Fax

Practice location:
  • Phone: 360-466-3167
  • Fax: 360-466-5528
Mailing address:
  • Phone: 360-466-3167
  • Fax: 360-466-5528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. RHONDA NELSON
Title or Position: CLINICAL APPLICATIONS COORDINATOR
Credential: D.P.M
Phone: 360-466-3167