Healthcare Provider Details

I. General information

NPI: 1316138696
Provider Name (Legal Business Name): COUNTRY DOCTOR COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 19TH AVE E
SEATTLE WA
98112-4007
US

IV. Provider business mailing address

500 19TH AVE E
SEATTLE WA
98112-4007
US

V. Phone/Fax

Practice location:
  • Phone: 206-299-1600
  • Fax: 206-299-1608
Mailing address:
  • Phone: 206-299-1600
  • Fax: 206-299-1608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: SHONNIE EVANS
Title or Position: QI MANAGER
Credential:
Phone: 206-299-1984