NPIMap

Organization Active NPI

Squaxin Island Tribe

  • Clinic/Center
  • Shelton, WA
National Provider Identifier
1669532578
Registry record updated Jun 17, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
SQUAXIN ISLAND TRIBE
Practice address
90 SE Klah Che Min Dr
Shelton, WA 98584-9216
Phone
(360) 427-9006
Fax
(360) 427-1951
NPI assigned
Dec 11, 2006
Last updated
Jun 17, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 17, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Edward J. Fox, PHD
Title
Director HHS
Phone
(360) 427-9006

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X WA Primary

Addresses

Primary practice location

90 SE Klah Che Min Dr
Shelton, WA 98584-9216

Mailing address

90 SE Klah Che Min Dr
Shelton, WA 98584-9216
Phone (360) 427-9006

Other identifiers 3

IdentifierTypeStateIssuer
1980994MedicaidWA
7047772MedicaidWA
7003767MedicaidWA

Other names 1

  • Squaxin Island Health Clinic Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040324000796 WA Part B Supplier - Clinic/Group Practice 2860383122 Receives reassigned benefits from 6 practitioners
Practice locations: Shelton, WA

National Provider Directory

National Provider Directory

Locations

10 SE Squaxin Ln
Shelton, WA 98584

Ownership & related parties

Subparts reporting this organization as parent 2

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165795200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1213660800000",
    "number": "1669532578",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "90 SE KLAH CHE MIN DR",
            "city": "SHELTON",
            "state": "WA",
            "postal_code": "985849216",
            "telephone_number": "360-427-9006",
            "fax_number": "360-427-1951"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "90 SE KLAH CHE MIN DR",
            "city": "SHELTON",
            "state": "WA",
            "postal_code": "985849216",
            "telephone_number": "360-427-9006",
            "fax_number": "360-427-1951"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SQUAXIN ISLAND TRIBE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-11",
        "last_updated": "2008-06-17",
        "status": "A",
        "authorized_official_last_name": "FOX",
        "authorized_official_first_name": "EDWARD",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "DIRECTOR HHS",
        "authorized_official_telephone_number": "360-427-9006",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "WA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1980994",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7047772",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7003767",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Squaxin Island Health Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Shelton, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.