Provider Demographics
NPI:1386864148
Name:INTERNATIONAL COMMUNITY HEALTH SERVICES
Entity Type:Organization
Organization Name:INTERNATIONAL COMMUNITY HEALTH SERVICES
Other - Org Name:HOLLY PARK MEDICAL AND DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT FINANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-788-3605
Mailing Address - Street 1:PO BOX 24911
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0911
Mailing Address - Country:US
Mailing Address - Phone:206-788-3600
Mailing Address - Fax:206-652-5216
Practice Address - Street 1:3815 S OTHELLO ST
Practice Address - Street 2:2ND FL.
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-3510
Practice Address - Country:US
Practice Address - Phone:206-788-3500
Practice Address - Fax:206-788-3521
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERNATIONAL COMMUNITY HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-26
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7094196Medicaid
WA7125297Medicaid