Organization
PORT GAMBLE S'KLALLAM TRIBE
Active
Other names
Port Gamble S'Klallam Health Center
Organization subpart
No
Provider details
NPI number
Authorized official
DALLAS I DEGUIRE (ADMINISTRATIVE DIRECTOR)
(360) 297-9601
Entity
Organization
Contact information
Practice address
32014 LITTLE BOSTON RD NE, KINGSTON, WA 98346-9734
(360) 297-9601
(360) 297-9614
Mailing address
32014 LITTLE BOSTON RD NE, KINGSTON, WA 98346-9734
(360) 297-9601
(360) 297-9614
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0101820
L&I CLINIC ID#
WA
05
—
1980929
—
WA
05
—
1992825
—
WA
05
—
5031794
—
WA
05
—
5031810
—
WA
05
—
7094964
—
WA
05
—
7094972
—
WA
01
—
PO1021
REGENCE RIDER#
WA
Enumeration date
06/21/2006
Last updated
01/07/2011
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