MEDICARE: URBAN IMPACT COMMUNITY HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1215265061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	URBAN IMPACT COMMUNITY HEALTH CENTER

Provider Business Mailing Address
First Line	:	7722 RAINIER AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118-4139
Country	:	US
Telephone Number	:	206-601-7200
Fax Number	:

Provider Business Practice Location Address
First Line	:	7722 RAINIER AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118-4139
Country	:	US
Telephone Number	:	206-601-7200
Fax Number	:

Authorized Official
Title or Position	:	CLINIC MANAGER
Name	:	MISS ELISABETH A KINGSLEY
Credential	:
Telephone Number	:	206-601-7200

Provider Enumeration Date	:	12/04/2009
Last Update Date	:	12/04/2009

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