Basic Information
Provider Information | |||||||||
NPI: | 1104140318 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SKAGIT FAMILY HEALTH CLINIC LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SKAGIT FAMILY HEALTH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 916 S 3RD ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982734324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603365658 | ||||||||
FaxNumber: | 3603365655 | ||||||||
Practice Location | |||||||||
Address1: | 916 S 3RD ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982734324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603365658 | ||||||||
FaxNumber: | 3603365655 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2010 | ||||||||
LastUpdateDate: | 10/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANTONICH | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3603365658 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175F00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Naturopath |   | 176B00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife |   | 363LF0000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.