Healthcare Provider Details

I. General information

NPI: 1669532578
Provider Name (Legal Business Name): SQUAXIN ISLAND TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 SE KLAH CHE MIN DR
SHELTON WA
98584-9216
US

IV. Provider business mailing address

90 SE KLAH CHE MIN DR
SHELTON WA
98584-9216
US

V. Phone/Fax

Practice location:
  • Phone: 360-427-9006
  • Fax: 360-427-1951
Mailing address:
  • Phone: 360-427-9006
  • Fax: 360-427-1951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateWA

VIII. Authorized Official

Name: EDWARD J. FOX
Title or Position: DIRECTOR HHS
Credential: PHD
Phone: 360-427-9006