Healthcare Provider Details

I. General information

NPI: 1013049741
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 194TH ST SW STE 100
LYNNWOOD WA
98036-4604
US

IV. Provider business mailing address

PO BOX 13060
EVERETT WA
98206-3060
US

V. Phone/Fax

Practice location:
  • Phone: 425-835-5200
  • Fax: 425-835-5201
Mailing address:
  • Phone: 425-789-3700
  • Fax: 425-789-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number7034036
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7034036
License Number StateWA

VIII. Authorized Official

Name: MR. KENNETH M GREEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 425-789-3700