Provider Demographics
NPI:1649567363
Name:SHOALWATER BAY WELLNESS CENTER
Entity Type:Organization
Organization Name:SHOALWATER BAY WELLNESS CENTER
Other - Org Name:SHOALWATER BAY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:F
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-267-8130
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:TOKELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98590-0500
Mailing Address - Country:US
Mailing Address - Phone:360-267-0119
Mailing Address - Fax:360-267-0417
Practice Address - Street 1:2373 TOKELAND ROAD BUILDING. E
Practice Address - Street 2:
Practice Address - City:TOKELAND
Practice Address - State:WA
Practice Address - Zip Code:98590-0500
Practice Address - Country:US
Practice Address - Phone:360-267-0119
Practice Address - Fax:360-267-0417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QR0405X261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP00005324OtherCDP