Provider Demographics
NPI:1457492936
Name:SNOQUALMIE VALLEY CLINIC, PLLC
Entity Type:Organization
Organization Name:SNOQUALMIE VALLEY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOKLEBUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-888-2299
Mailing Address - Street 1:PO BOX 2013
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-2013
Mailing Address - Country:US
Mailing Address - Phone:425-888-2299
Mailing Address - Fax:425-888-1204
Practice Address - Street 1:38700 SE RIVER ST
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-2013
Practice Address - Country:US
Practice Address - Phone:425-888-2299
Practice Address - Fax:425-888-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7020753Medicaid
WA7020753Medicaid
WAGAB04690Medicare PIN