Provider Demographics
NPI:1760428650
Name:PORT GAMBLE S'KLALLAM TRIBE
Entity Type:Organization
Organization Name:PORT GAMBLE S'KLALLAM TRIBE
Other - Org Name:PORT GAMBLE S'KLALLAM HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:I
Authorized Official - Last Name:DEGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-297-9601
Mailing Address - Street 1:32014 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:360-297-9601
Mailing Address - Fax:360-297-9614
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:360-297-9601
Practice Address - Fax:360-297-9614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1980929Medicaid
WA1992825Medicaid
WA5031810Medicaid
WA7094964Medicaid
WA7094972Medicaid
WAPO1021OtherREGENCE RIDER#
WA0101820OtherL&I CLINIC ID#
WA5031794Medicaid
WA7094972Medicaid
WA7094972Medicaid
WA50-1839Medicare Oscar/Certification