Healthcare Provider Details

I. General information

NPI: 1174057350
Provider Name (Legal Business Name): GUMSHOE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 OLIVE WAY STE 755
SEATTLE WA
98101-1720
US

IV. Provider business mailing address

509 OLIVE WAY STE 755
SEATTLE WA
98101-1720
US

V. Phone/Fax

Practice location:
  • Phone: 206-420-8682
  • Fax: 360-282-0006
Mailing address:
  • Phone: 206-420-8682
  • Fax: 360-282-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number6035903030010001
License Number StateWA

VIII. Authorized Official

Name: DR. SAMANTHA DESMOND
Title or Position: PRESIDENT
Credential: ND, LMP
Phone: 206-747-7681