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General NPI Number Information
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NPI Number | 1255571063
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Entity Type | Organization
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Legal Business Name | CAPITAL CLUBHOUSE
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Dates
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Enumeration Date | 03/06/2009
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Last Update Date | 06/03/2021
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Provider Practice Location Address
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Address Line | 1000 CHERRY ST SE
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City | OLYMPIA
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State | WA
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Zip | 98501-1433
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Country | US
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Telephone | 360-357-2582
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Fax | 360-357-2821
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Provider Business Mailing Address
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Address Line | 1000 CHERRY ST SE
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City | OLYMPIA
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State | WA
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Zip | 98501-1433
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Country | US
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Telephone | 360-357-2582
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Fax | 360-357-2821
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | KATRINA RACHELE MCCOY
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Credential |
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Telephone | 360-357-2582
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 601-217-168
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License Number State | WA
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