Provider Demographics
NPI:1558448175
Name:MUCKLESHOOT INDIAN TRIBE
Entity Type:Organization
Organization Name:MUCKLESHOOT INDIAN TRIBE
Other - Org Name:MUCKLESHOOT HEALTH AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN-SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-939-6648
Mailing Address - Street 1:17500 SE 392ND ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-9705
Mailing Address - Country:US
Mailing Address - Phone:253-939-6648
Mailing Address - Fax:253-887-8737
Practice Address - Street 1:17500 SE 392ND ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-9705
Practice Address - Country:US
Practice Address - Phone:253-939-6648
Practice Address - Fax:253-887-8737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUCKLESHOOT INDIAN TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WATEZ001Medicare ID - Type Unspecified