Healthcare Provider Details

I. General information

NPI: 1598973158
Provider Name (Legal Business Name): SQUAXIN ISLAND MEDICAL ENCOUNTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 08/22/2020
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:
Mailing address:
  • Phone: 360-427-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WHITNEY JONES
Title or Position: DIRECTOR
Credential:
Phone: 360-427-9006