Healthcare Provider Details

I. General information

NPI: 1316012461
Provider Name (Legal Business Name): SEATTLE INDIAN HEALTH BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 12TH AVE S
SEATTLE WA
98144-1910
US

IV. Provider business mailing address

611 12TH AVE S
SEATTLE WA
98144-1910
US

V. Phone/Fax

Practice location:
  • Phone: 206-324-9360
  • Fax: 206-324-8910
Mailing address:
  • Phone: 206-324-9360
  • Fax: 206-324-8910

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: ESHTER LUCERO
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 206-324-9360