Provider Demographics
NPI:1518585579
Name:PORT GAMBLE S'KLALLAM TRIBE
Entity Type:Organization
Organization Name:PORT GAMBLE S'KLALLAM TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICES BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KERSTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-297-9649
Mailing Address - Street 1:32020 LITTLE BOSTON RD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-9734
Mailing Address - Country:US
Mailing Address - Phone:360-297-9614
Mailing Address - Fax:
Practice Address - Street 1:32014 LITTLE BOSTON RD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9734
Practice Address - Country:US
Practice Address - Phone:360-297-9614
Practice Address - Fax:360-297-9614
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORT GAMBLE S'KLALLAM TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)