1104340405 NPI number — SWEET MEDICAL GROUP, PLLC

Table of content: (NPI 1104340405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104340405 NPI number — SWEET MEDICAL GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SWEET MEDICAL GROUP, 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:
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:
1104340405
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 944
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98540-0944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-491-9890
Provider Business Mailing Address Fax Number:
360-667-5135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4524 INTELCO LOOP SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98503-5941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-491-9890
Provider Business Practice Location Address Fax Number:
360-667-5135
Provider Enumeration Date:
07/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SWEET
Authorized Official First Name:
BETHANY
Authorized Official Middle Name:
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
360-491-9890

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD60155686 , 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)

  • Identifier: 1821240904 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G8902804 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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