Provider Demographics
NPI:1558642017
Name:VILLAGE INTEGRATIVE CARE, P.S.
Entity Type:Organization
Organization Name:VILLAGE INTEGRATIVE CARE, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:JOHNIE
Authorized Official - Last Name:SHELBY
Authorized Official - Suffix:
Authorized Official - Credentials:ND LM
Authorized Official - Phone:205-363-5555
Mailing Address - Street 1:6300 9TH AVE NE STE 300
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-8516
Mailing Address - Country:US
Mailing Address - Phone:206-363-5555
Mailing Address - Fax:206-363-5533
Practice Address - Street 1:6300 9TH AVE NE STE 300
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-8516
Practice Address - Country:US
Practice Address - Phone:206-363-5555
Practice Address - Fax:206-363-5533
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VILLAGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-29
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty