MEDICARE: NOOKSACK CENTRAL MANAGEMENT SYSTEM

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0170843	OTHER	WA	LABOR & INDUSTRIES
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568528842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOOKSACK CENTRAL MANAGEMENT SYSTEM

Provider Business Mailing Address
First Line	:	PO BOX 157
Second Line	:
City	:	DEMING
State	:	WA
Zip	:	98244-0157
Country	:	US
Telephone Number	:	360-966-2106
Fax Number	:	360-966-7227

Provider Business Practice Location Address
First Line	:	6760 MISSION RD
Second Line	:
City	:	EVERSON
State	:	WA
Zip	:	98247-9749
Country	:	US
Telephone Number	:	360-966-2106
Fax Number	:	360-966-7227

Authorized Official
Title or Position	:	NIT CONTROLLER
Name	:	JOHN DUNCAN
Credential	:
Telephone Number	:	360-296-2315

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	03/02/2009

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1891843769 — NOOKSACK DENTAL CLINIC
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1932257144 — MARY ELLEN SHIELDS M.D.
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1669521704 — DR. DIANE R STAVES M.D.
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Directions to “NOOKSACK CENTRAL MANAGEMENT SYSTEM ” Practice Location

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