Provider Demographics
NPI:1669504395
Name:COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY
Other - Org Name:CHC OF SNOHOMISH COUNTY 112TH MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-789-3700
Mailing Address - Street 1:PO BOX 13060
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-3060
Mailing Address - Country:US
Mailing Address - Phone:425-789-3700
Mailing Address - Fax:425-789-3750
Practice Address - Street 1:1019 112TH ST SW
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204
Practice Address - Country:US
Practice Address - Phone:425-551-6200
Practice Address - Fax:425-551-6017
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7034036207Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7034036Medicaid
WA8934243OtherCRIME VICTIMS COMP
WA32770OtherWORKER COMPENSATION
WA8934243OtherCRIME VICTIMS COMP
WA32770OtherWORKER COMPENSATION