Provider Demographics
NPI:1174057350
Name:GUMSHOE HEALTH
Entity type:Organization
Organization Name:GUMSHOE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LMP
Authorized Official - Phone:206-747-7681
Mailing Address - Street 1:509 OLIVE WAY
Mailing Address - Street 2:STE 755
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1720
Mailing Address - Country:US
Mailing Address - Phone:206-420-8682
Mailing Address - Fax:360-282-0006
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:STE 755
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1720
Practice Address - Country:US
Practice Address - Phone:206-420-8682
Practice Address - Fax:360-282-0006
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUMSHOE HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6035903030010001261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1659725455Medicaid