MEDICARE: SEATTLE INDIAN HEALTH BOARD

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1750956181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEATTLE INDIAN HEALTH BOARD

Provider Business Mailing Address
First Line	:	611 12TH AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98144-2007
Country	:	US
Telephone Number	:	206-324-9360
Fax Number	:

Provider Business Practice Location Address
First Line	:	12736 33RD AVE NE # 200
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-4504
Country	:	US
Telephone Number	:	206-324-9360
Fax Number	:

Authorized Official
Title or Position	:	REVENUE CYCLE MANAGER
Name	:	ANGELA LAFONTAINE
Credential	:
Telephone Number	:	206-324-4036

Provider Enumeration Date	:	05/27/2021
Last Update Date	:	05/27/2021

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