Provider Demographics
NPI:1285757450
Name:TACOMA DETOXIFICATION CENTER
Entity type:Organization
Organization Name:TACOMA DETOXIFICATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DEGRUY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-284-7821
Mailing Address - Street 1:721S FAWCETT
Mailing Address - Street 2:STE 100
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5502
Mailing Address - Country:US
Mailing Address - Phone:253-593-2413
Mailing Address - Fax:253-627-4817
Practice Address - Street 1:721 FAWCETT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5502
Practice Address - Country:US
Practice Address - Phone:253-593-2413
Practice Address - Fax:253-627-4817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARTF1067324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1994219Medicaid