Healthcare Provider Details

I. General information

NPI: 1558642017
Provider Name (Legal Business Name): VILLAGE INTEGRATIVE CARE, P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 9TH AVE NE STE 300
SEATTLE WA
98115-8516
US

IV. Provider business mailing address

6300 9TH AVE NE STE 300
SEATTLE WA
98115-8516
US

V. Phone/Fax

Practice location:
  • Phone: 206-363-5555
  • Fax: 206-363-5533
Mailing address:
  • Phone: 206-363-5555
  • Fax: 206-363-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TARA JOHNIE SHELBY
Title or Position: EXECUTIVE DIRECTOR
Credential: ND LM
Phone: 205-363-5555