Provider Demographics
NPI:1023226685
Name:SQUAXIN ISLAND TRIBE
Entity type:Organization
Organization Name:SQUAXIN ISLAND TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HHS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-427-9006
Mailing Address - Street 1:90 SE KLAH CHE MIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584
Mailing Address - Country:US
Mailing Address - Phone:360-427-9006
Mailing Address - Fax:360-427-1951
Practice Address - Street 1:90 SE KLAH CHE MIN DRIVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584
Practice Address - Country:US
Practice Address - Phone:360-427-9006
Practice Address - Fax:360-427-1951
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SQUAXIN ISLAND TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-18
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600371470261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1980994Medicaid