Healthcare Provider Details

I. General information

NPI: 1235778812
Provider Name (Legal Business Name): SEATTLE INDIAN HEALTH BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 2ND AVE S
SEATTLE WA
98104-5168
US

IV. Provider business mailing address

611 12TH AVE S
SEATTLE WA
98144-2007
US

V. Phone/Fax

Practice location:
  • Phone: 206-292-6214
  • Fax:
Mailing address:
  • Phone: 206-324-9360
  • Fax: 206-899-1682

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: YVETTE YAZZIE
Title or Position: CREDENTIALING
Credential: DO
Phone: 206-324-9360