1063748861 NPI number — MARANATHA MEDICAL CLINIC INC P S

Table of content: (NPI 1063748861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063748861 NPI number — MARANATHA MEDICAL CLINIC INC P S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARANATHA MEDICAL CLINIC INC P S
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063748861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17900 TALBOT ROAD SOUTH
Provider Second Line Business Mailing Address:
#101
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98055-8636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-235-9614
Provider Business Mailing Address Fax Number:
425-235-1060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17900 TALBOT RD S
Provider Second Line Business Practice Location Address:
#101
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98055-8212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-235-9614
Provider Business Practice Location Address Fax Number:
425-235-1060
Provider Enumeration Date:
10/29/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRAVES
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
425-235-9614

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  17917 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)