Healthcare Provider Details

I. General information

NPI: 1043873722
Provider Name (Legal Business Name): SNOQUALMIE INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9575 ETHAN WADE WAY SE
SNOQUALMIE WA
98065-9577
US

IV. Provider business mailing address

PO BOX 969 ATTN COMPLIANCE MANAGER
SNOQUALMIE WA
98065-0969
US

V. Phone/Fax

Practice location:
  • Phone: 425-831-5425
  • Fax: 425-831-5428
Mailing address:
  • Phone: 425-831-5425
  • Fax: 425-831-5428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEAN MEDINA
Title or Position: COMPLIANCE MANAGER
Credential:
Phone: 425-831-5425