1548222102 NPI number — LAKE FOREST PARK CLINIC TR

Table of content: (NPI 1548222102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548222102 NPI number — LAKE FOREST PARK CLINIC TR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE FOREST PARK CLINIC TR
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:
1548222102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17191 BOTHELL WAY NE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
LAKE FOREST PARK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98155-5534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-365-6768
Provider Business Mailing Address Fax Number:
206-364-5418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17191 BOTHELL WAY NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE FOREST PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98155-5534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-365-6768
Provider Business Practice Location Address Fax Number:
206-364-5418
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHNEIDER
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRES/CEO
Authorized Official Telephone Number:
206-368-1700

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)

  • Identifier: CJ6346 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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