Provider Demographics
NPI:1356797484
Name:SHANNON REITAN
Entity type:Organization
Organization Name:SHANNON REITAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:REITAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-637-4425
Mailing Address - Street 1:520 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-8057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 SPRING ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-8057
Practice Address - Country:US
Practice Address - Phone:817-637-4425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-07
Last Update Date:2016-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60629779302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization