MEDICARE: NISQUALLY TRIBE

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	261QM0850X	Adult Mental Health Clinic/Center		WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558553008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NISQUALLY TRIBE

Provider Business Mailing Address
First Line	:	4816 SHE NAH NUM DR SE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98513-9105
Country	:	US
Telephone Number	:	360-459-5312
Fax Number	:	360-407-0860

Provider Business Practice Location Address
First Line	:	4816 SHE NAH NUM DR SE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98513-9105
Country	:	US
Telephone Number	:	360-459-5312
Fax Number	:	360-407-0860

Authorized Official
Title or Position	:	HEALTH DIRECTOR
Name	:	MS. RENA WELLS
Credential	:
Telephone Number	:	360-459-5312

Provider Enumeration Date	:	08/17/2007
Last Update Date	:	08/17/2007

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Practice Location Address:

4816 SHE NAH NUM DR SE
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98513-9105

Practice Phone: 360-459-5312
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1295887461 — ELIZABETH H SIEGEL ARNP
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1790907582 — MR. JOHN HUANGSEN CHIU PA
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4816 SHE NAH NUM DR SE
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Practice Fax:

1851504757 — DR. MARK DOUGLAS TEIGEN D.D.S.
Practice Location Address:

4818B SHE NAH NUM DR SE
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98513-9105

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Practice Fax:

1003020215 — DR. ROSEMARY ELAINE ENGLE D.D.S.
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1184815524 — NISQUALLY TRIBE HEALTH CLINIC
Practice Location Address:

4816 SHE NAH NUM DR SE
OLYMPIA, WA
98513-9105

Practice Phone: 360-459-5312
Practice Fax: 360-407-0860

Directions to “NISQUALLY TRIBE ” Practice Location

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