Provider Demographics
NPI:1164451142
Name:STILLAGUAMISH TRIBAL HEALTH CLINIC
Entity Type:Organization
Organization Name:STILLAGUAMISH TRIBAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANNIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-631-5971
Mailing Address - Street 1:24205 JAMES DORSEY WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-6029
Mailing Address - Country:US
Mailing Address - Phone:360-435-9338
Mailing Address - Fax:360-435-2266
Practice Address - Street 1:24205 JAMES DORSEY WAY STE 1
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-6029
Practice Address - Country:US
Practice Address - Phone:360-435-9338
Practice Address - Fax:360-435-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X
WAAP30001255261QC1500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8456352Medicaid
WA9600198Medicaid
WA2093558Medicaid
WAMT0116093OtherDEA NUMBER