=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114058195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 06/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4111 194TH ST SW SUITE 200
-----------------------------------------------------
City | LYNNWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98036-4604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-835-5204
-----------------------------------------------------
Fax | 425-835-5205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 13060
-----------------------------------------------------
City | EVERETT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98206-3060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-789-3700
-----------------------------------------------------
Fax | 425-789-3750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PT ACCOUNT MANAGER
-----------------------------------------------------
Name | MR. KENNETH M GREEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-789-3700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7034036
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------