=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831910439
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNATIONAL COMMUNITY HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2024
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4238 AUBURN WAY N
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98002-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-444-0106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3007
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98114-3007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-444-0106
-----------------------------------------------------
Fax | 253-733-0893
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | HERMES SHAHBAZIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 206-788-3618
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------