| Details | Last Recertification Date | Update | Recertification | 2/27/2024 12:16:37 PM | 2/10/2025 12:30:05 PM | 2/10/2025 12:30 PM |
| Details | Last Recertification Date | Update | Recertification | 2/25/2023 8:25:15 AM | 2/27/2024 12:16:37 PM | 2/27/2024 12:16 PM |
| Addresses | Main Address | Update | Recertification |
80 N. TRIBAL CENTER ROAD
SKOKOMISH NATION, WA 98584 |
100 N. TRIBAL CENTER ROAD
SKOKOMISH NATION, WA 98584 | 2/25/2023 8:25 AM |
| Contacts | Primary Contact | Update | Recertification | Shaw, Margie
CAC/Lab Manager
Skokomish Tribe
3604265755-2188 | Burfiend, Beth Marie
Billing and Benefits Specialist
Skokomish Health Center
3604265755-2101 | 2/25/2023 8:25 AM |
| Details | Last Recertification Date | Update | Recertification | 2/25/2022 2:58:28 PM | 2/25/2023 8:25:15 AM | 2/25/2023 8:25 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | LaClair, Denese LaClair
Health Director
Skokomish Tribe
3604904596-2118 | LaClair, Denese LaClair
Health Director
Skokomish Tribe
3604265755-2118 | 9/1/2022 2:15 PM |
| Contacts | Primary Contact | Update | Change Request | Miller, Karla
Dupty Director
Skokomish Health Center
3604265755-2142 | Shaw, Margie
CAC/Lab Manager
Skokomish Tribe
3604265755-2188 | 2/28/2022 7:34 AM |
| Details | Last Recertification Date | Update | Recertification | 2/5/2021 6:13:21 PM | 2/25/2022 2:58:28 PM | 2/25/2022 2:58 PM |
| Contacts | Authorizing Official | Update | AO Change Request | LONGSHORE, FRANCES L
BUSINESS OFFICE SPECIALIST
SKOKOMISH HEALTH CENTER/CLINIC
3604265755-2120 | LaClair, Denese LaClair
Health Director
Skokomish Tribe
3604904596-2118 | 2/25/2022 1:35 PM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2020 8:32:26 AM | 2/5/2021 6:13:21 PM | 2/5/2021 6:13 PM |
| Contacts | Primary Contact | Update | Recertification | LONGSHORE, AUDRY SMITH
PRC REFERRAL COODINATOR
SKOKOMISH HEALTH CENTER/CLINIC
3604265755-2008 | Miller, Karla
Dupty Director
Skokomish Health Center
3604265755-2142 | 1/29/2020 8:32 AM |
| Details | Last Recertification Date | Update | Recertification | 2/5/2019 2:52:18 PM | 1/29/2020 8:32:26 AM | 1/29/2020 8:32 AM |
| Details | Last Recertification Date | Update | Recertification | 2/16/2018 2:03:30 PM | 2/5/2019 2:52:18 PM | 2/5/2019 2:52 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | LONGSHORE, FRANCES L
BUSINESS OFFICE MANAGER
SKOKOMISH HEALTH CENTER/CLINIC
3604265755-2120 | LONGSHORE, FRANCES L
BUSINESS OFFICE SPECIALIST
SKOKOMISH HEALTH CENTER/CLINIC
3604265755-2120 | 2/5/2019 2:48 PM |
| Contacts | Primary Contact | Update | Recertification | LONGSHORE, FRANCES L
BUSINESS OFFICE MANAGER
SKOKOMISH HEALTH CENTER/CLINIC
3604265755-2120 | LONGSHORE, AUDRY SMITH
PRC REFERRAL COODINATOR
SKOKOMISH HEALTH CENTER/CLINIC
3604265755-2008 | 2/16/2018 2:03 PM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2017 12:00:00 AM | 2/16/2018 2:03:30 PM | 2/16/2018 2:03 PM |
| Contacts | Authorizing Official | Update | | LONGSHORE, FRANCES
BUSINESS OFFICE MANAGER
3604265755-2120 | LONGSHORE, FRANCES L
BUSINESS OFFICE MANAGER
SKOKOMISH HEALTH CENTER/CLINIC
3604265755-2120 | 12/22/2017 2:00 PM |
| Contacts | Primary Contact | Update | | LONGSHORE, FRANCES
BUSINESS OFFICE MANAGER
3604265755-2120 | LONGSHORE, FRANCES L
BUSINESS OFFICE MANAGER
SKOKOMISH HEALTH CENTER/CLINIC
3604265755-2120 | 12/22/2017 2:00 PM |
| Addresses | Main Address | Insert | | |
80 N. TRIBAL CENTER ROAD
SKOKOMISH NATION, WA 98584 | 2/7/2017 8:36 PM |
| Contacts | Authorizing Official | Update | | ESTRADA, MARTIN
HEALTH ADMINISTRATOR
3604265755-2020 | LONGSHORE, FRANCES
BUSINESS OFFICE MANAGER
3604265755-2120 | 2/7/2017 8:36 PM |
| Contacts | Primary Contact | Update | | ESTRADA, MARTIN
HEALTH ADMINISTRATOR
3604265755-2020 | LONGSHORE, FRANCES
BUSINESS OFFICE MANAGER
3604265755-2120 | 2/7/2017 8:36 PM |
| Details | Last Recertification Date | Update | | 2/16/2016 12:00:00 AM | 2/7/2017 12:00:00 AM | 2/7/2017 8:36 PM |
| Details | Last Recertification Date | Update | | 1/30/2015 12:00:00 AM | 2/16/2016 12:00:00 AM | 2/16/2016 4:47 PM |
| Details | Last Recertification Date | Update | | 3/14/2014 12:00:00 AM | 1/30/2015 12:00:00 AM | 1/30/2015 4:17 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/14/2014 12:00:00 AM | 3/14/2014 7:23 PM |
| Addresses | Billing Address | Insert | | | SKOKOMISH INDIAN TRIBE / HEALTH CENTER
100 N. TRIBAL CENTER ROAD
SKOKOMISH NATION, WA 98584 | 3/14/2014 6:03 PM |
| Contacts | Authorizing Official | Update | | PAVEL, JOSEPH
TRIBAL CHAIRPERSON
3604264232 | ESTRADA, MARTIN
HEALTH ADMINISTRATOR
3604265755-2020 | 3/14/2014 6:03 PM |
| Contacts | Primary Contact | Update | | Walker, Denise
HEALTH ADMINISTRATOR
3604265755 | ESTRADA, MARTIN
HEALTH ADMINISTRATOR
3604265755-2020 | 3/14/2014 6:03 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/11/2013 7:14 AM |
| Contacts | Authorizing Official | Insert | | | PAVEL, JOSEPH
TRIBAL CHAIRPERSON
3604264232 | 1/14/2013 2:50 PM |
| Contacts | Primary Contact | Update | | CROCKER, REBECCA
HEALTH ADMINISTRATOR
3604265755 | Walker, Denise
HEALTH ADMINISTRATOR
3604265755 | 11/17/2011 2:51 PM |
| Contacts | Primary Contact | Insert | | | CROCKER, REBECCA
HEALTH ADMINISTRATOR
3604265755 | 6/1/2009 11:50 AM |
| Details | Last Recertification Date | Insert | | | | 6/1/2009 11:50 AM |
| Details | Grant Number | Insert | | | | 6/1/2009 11:50 AM |
| Details | 340B ID | Insert | | | FQHC638345 | 6/1/2009 11:50 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 6/1/2009 11:50 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 6/1/2009 11:50 AM |
| Details | Medicare Provider Number | Insert | | | | 6/1/2009 11:50 AM |
| Details | Entity Name | Insert | | | SKOKOMISH INDIAN TRIBE | 6/1/2009 11:50 AM |
| Details | Program Code | Insert | | | FQHC638 | 6/1/2009 11:50 AM |
| Details | Entity Subname | Insert | | | | 6/1/2009 11:50 AM |
| Dates | Participating Approval Date | Insert | | | 6/1/2009 12:00:00 AM | 6/1/2009 11:50 AM |
| Details | State | Insert | | | Active | 6/1/2009 11:50 AM |
| Dates | Registration Date | Insert | | | 6/1/2009 12:00:00 AM | 6/1/2009 11:50 AM |
| Dates | Signed By Date | Insert | | | 4/16/2009 12:00:00 AM | 6/1/2009 11:50 AM |
| Dates | Start Date | Insert | | | 7/1/2009 12:00:00 AM | 6/1/2009 11:50 AM |
| Terminations | Termination Comments | Insert | | | | 6/1/2009 11:50 AM |
| Terminations | Termination Date | Insert | | | | 6/1/2009 11:50 AM |
| Terminations | Termination Effective Date | Insert | | | | 6/1/2009 11:50 AM |
| Terminations | Termination Reason | Insert | | | | 6/1/2009 11:50 AM |