Provider Demographics
NPI:1891343075
Name:COUNTRY DOCTOR COMMUNITY CLINIC
Entity Type:Organization
Organization Name:COUNTRY DOCTOR COMMUNITY CLINIC
Other - Org Name:COUNTRY DOCTOR HEP C CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:SUSANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TANTICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-299-1937
Mailing Address - Street 1:2101 E YESLER WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5959
Mailing Address - Country:US
Mailing Address - Phone:206-299-1937
Mailing Address - Fax:206-299-1920
Practice Address - Street 1:1621 S JACKSON ST STE 201
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2277
Practice Address - Country:US
Practice Address - Phone:206-299-1900
Practice Address - Fax:206-299-1900
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTRY DOCTOR COMMUNITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-30
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUBI601583685OtherDEPARTMENT OF REVENUE