Healthcare Provider Details

I. General information

NPI: 1114540457
Provider Name (Legal Business Name): SEATTLE ROOTS COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2020
Last Update Date: 06/05/2025
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 E CHERRY ST
SEATTLE WA
98122
US

IV. Provider business mailing address

2101 E YESLER WAY SUITE 210
SEATTLE WA
98122-5959
US

V. Phone/Fax

Practice location:
  • Phone: 206-709-7166
  • Fax: 206-299-1920
Mailing address:
  • Phone: 206-709-7112
  • Fax: 206-299-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ANGIE J TREPTOW
Title or Position: INTERIM FINANCE DIRECTOR
Credential:
Phone: 253-299-1937