=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639805724
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PROMISE OF SKAGIT VALLEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2022
-----------------------------------------------------
Last Update Date | 07/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1013 POLTE RD
-----------------------------------------------------
City | SEDRO WOOLLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98284-9478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-854-0743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 335
-----------------------------------------------------
City | SEDRO WOOLLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98284-0335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-854-0743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DONOR RELATIONS/BOOKKEEPER
-----------------------------------------------------
Name | JASON BOOMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-854-0743
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------