1053798546 NPI number — SPECTRUM CARE, PLLC

Table of content: (NPI 1053798546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053798546 NPI number — SPECTRUM CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM CARE, 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:
1053798546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5908 149TH PL SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMONDS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-210-4187
Provider Business Mailing Address Fax Number:
425-361-1704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16825 48TH AVE W
Provider Second Line Business Practice Location Address:
117
Provider Business Practice Location Address City Name:
LYNNWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98037-6401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-210-4187
Provider Business Practice Location Address Fax Number:
425-361-1704
Provider Enumeration Date:
05/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
COLLISON-RIS
Authorized Official First Name:
KIMBERLY 'KIMMER'
Authorized Official Middle Name:
VERLYNN
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
42521041187

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP30006553 , 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)





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