Healthcare Provider Details

I. General information

NPI: 1649567363
Provider Name (Legal Business Name): SHOALWATER BAY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 TOKELAND ROAD BUILDING. E
TOKELAND WA
98590-0500
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 Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number261QR0405X
License Number StateWA

VIII. Authorized Official

Name: MR. F SCOTT POWELL
Title or Position: HEALTH DIRECTOR
Credential: DC.
Phone: 360-267-8130