Basic Information
| Provider Information | |||||||||
| NPI: | 1386380533 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE EVERETT CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982065127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1425304843 | ||||||||
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| Practice Location | |||||||||
| Address1: | 904 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253395453 | ||||||||
| FaxNumber: | 4252524441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2022 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | SLACK | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BOARD PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4252590966 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EVERETT PHYSICIANS INC. P.S. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.