Provider Demographics
NPI:1467905695
Name:PACIFIC ISLAMIC COMMUNITY AND CULTURAL SERVICES
Entity Type:Organization
Organization Name:PACIFIC ISLAMIC COMMUNITY AND CULTURAL SERVICES
Other - Org Name:PICACS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:JAMAL
Authorized Official - Last Name:MUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-806-5021
Mailing Address - Street 1:10634 E RIVERSIDE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3757
Mailing Address - Country:US
Mailing Address - Phone:425-412-6318
Mailing Address - Fax:
Practice Address - Street 1:10634 E RIVERSIDE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3757
Practice Address - Country:US
Practice Address - Phone:425-412-6318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-23
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA200385251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health