Provider Demographics
NPI:1043873722
Name:SNOQUALMIE INDIAN TRIBE
Entity type:Organization
Organization Name:SNOQUALMIE INDIAN TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-831-5425
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:ATTN COMPLIANCE MANAGER
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-0969
Mailing Address - Country:US
Mailing Address - Phone:425-831-5425
Mailing Address - Fax:425-831-5428
Practice Address - Street 1:9575 ETHAN WADE WAY SE
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-9577
Practice Address - Country:US
Practice Address - Phone:425-831-5425
Practice Address - Fax:425-831-5428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-17
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2137735Medicaid