Healthcare Provider Details

I. General information

NPI: 1659725455
Provider Name (Legal Business Name): GUMSHOE HEALTH, P.S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MAIN ST STE 201
MONROE WA
98272-1519
US

IV. Provider business mailing address

101 E MAIN ST STE 201
MONROE WA
98272-1519
US

V. Phone/Fax

Practice location:
  • Phone: 360-863-0642
  • Fax: 360-794-7236
Mailing address:
  • Phone: 360-863-0642
  • Fax: 360-794-7236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberNT60647845
License Number StateWA

VIII. Authorized Official

Name: DR. SAMANTHA DESMOND
Title or Position: PRESIDENT
Credential: ND, LMP
Phone: 206-747-7681