Provider Demographics
NPI:1063455665
Name:PUYALLUP TRIBAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:PUYALLUP TRIBAL HEALTH AUTHORITY
Other - Org Name:TAKOPID HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-593-0232
Mailing Address - Street 1:2209 E 32ND ST
Mailing Address - Street 2:P.O. BOX 8009
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-4922
Mailing Address - Country:US
Mailing Address - Phone:253-593-0232
Mailing Address - Fax:253-382-2091
Practice Address - Street 1:2209 E 32ND ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404
Practice Address - Country:US
Practice Address - Phone:253-593-0232
Practice Address - Fax:253-382-2091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QD0000X
261QH0100X, 261QP1100X, 261QP2000X, 261QP2300X, 261QR0200X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPO1874OtherREGENCE CLINIC ID
WA366486001OtherGROUP HEALTH OPTIONS-CLIN
WA7090954Medicaid
WA0042440OtherLABOR & INDUSTRIES CLINIC
WA7013220Medicaid
WA5035233Medicaid
WA366486001OtherGROUP HEALTH OPTIONS-CD
WA001054300Medicare ID - Type UnspecifiedCLINIC MEDICARE ID