Healthcare Provider Details

I. General information

NPI: 1063624740
Provider Name (Legal Business Name): SHOALWATER BAY TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 OLD TOKELAND RD
TOKELAND WA
98590
US

IV. Provider business mailing address

PO BOX 500
TOKELAND WA
98590-0500
US

V. Phone/Fax

Practice location:
  • Phone: 360-267-0119
  • Fax: 360-267-0417
Mailing address:
  • Phone: 360-267-0119
  • Fax: 360-267-0417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL ROGERS
Title or Position: TRIBAL ADMINISTRATOR
Credential:
Phone: 360-267-6766