1104962331 NPI number — SOUTHLAKE CLINIC INC., P.S.

Table of content: (NPI 1104962331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104962331 NPI number — SOUTHLAKE CLINIC INC., P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHLAKE 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:
VALLEY INTERNAL MEDICINE INC PS
Provider Other Organization Name Type Code:
4
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:
1104962331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 59028
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98058-2028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-251-5110
Provider Business Mailing Address Fax Number:
425-277-1301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4011 TALBOT RD S
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98055-5773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-251-5110
Provider Business Practice Location Address Fax Number:
425-793-4707
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HUDSON
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
DWIGHT
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
425-793-4725

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0901X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7072440 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS3809 . This is a "RR MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0057600 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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