Provider Demographics
NPI:1336145846
Name:DIETRICH & SMITH CLINIC INC P S
Entity Type:Organization
Organization Name:DIETRICH & SMITH CLINIC INC P S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KARYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-856-4141
Mailing Address - Street 1:2241 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-4326
Mailing Address - Country:US
Mailing Address - Phone:360-856-4141
Mailing Address - Fax:360-856-4145
Practice Address - Street 1:2241 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-4326
Practice Address - Country:US
Practice Address - Phone:360-856-4141
Practice Address - Fax:360-856-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7080559Medicaid
WA47990OtherWASH STATE LABOR & INDUST