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General NPI Number Information
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NPI Number | 1669532578
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Entity Type | Organization
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Legal Business Name | SQUAXIN ISLAND TRIBE
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 06/17/2008
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Provider Practice Location Address
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Address Line | 90 SE KLAH CHE MIN DR
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City | SHELTON
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State | WA
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Zip | 98584-9216
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Country | US
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Telephone | 360-427-9006
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Fax | 360-427-1951
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Provider Business Mailing Address
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Address Line | 90 SE KLAH CHE MIN DR
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City | SHELTON
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State | WA
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Zip | 98584-9216
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Country | US
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Telephone | 360-427-9006
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Fax | 360-427-1951
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Authorized Official
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Title or Position | DIRECTOR HHS
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Name | EDWARD J. FOX
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Credential | PHD
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Telephone | 360-427-9006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | WA
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