Provider Demographics
NPI:1164483285
Name:SWINOMISH INDIAN TRIBAL COMMUNITY
Entity Type:Organization
Organization Name:SWINOMISH INDIAN TRIBAL COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL APPLICATIONS COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-466-3167
Mailing Address - Street 1:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-0683
Mailing Address - Country:US
Mailing Address - Phone:360-466-3167
Mailing Address - Fax:360-466-5528
Practice Address - Street 1:17400 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-8801
Practice Address - Country:US
Practice Address - Phone:360-466-3167
Practice Address - Fax:360-466-5528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7084320Medicaid
WA7084320Medicaid