Healthcare Provider Details

I. General information

NPI: 1992582613
Provider Name (Legal Business Name): PUYALLUP TRIBAL OPIOID CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 EAST 26TH ST
TACOMA WA
98421
US

IV. Provider business mailing address

6650 GUNPARK DR STE 100
BOULDER CO
80301-7003
US

V. Phone/Fax

Practice location:
  • Phone: 253-881-7001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT LOUIS KERSHNER
Title or Position: MANAGER
Credential:
Phone: 303-859-2742