1063010957 NPI number — OLYMPIC MEDICAL PLLC

Table of content: (NPI 1063010957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063010957 NPI number — OLYMPIC MEDICAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLYMPIC MEDICAL PLLC
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:
6
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:
1063010957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1410 PUGET ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98506-4153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-410-5998
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6342 LITTLEROCK RD SW BLDG 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUMWATER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98512-7332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-410-5998
Provider Business Practice Location Address Fax Number:
425-217-0945
Provider Enumeration Date:
10/13/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCHWARTZ
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/CLINIC OWNER
Authorized Official Telephone Number:
425-410-5998

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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