MEDICARE: OLYMPIC PENINSULA KIDNEY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386694099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLYMPIC PENINSULA KIDNEY CENTER

Provider Business Mailing Address
First Line	:	450 S KITSAP BLVD
Second Line	:	SUITE 178
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-3773
Country	:	US
Telephone Number	:	360-895-7795
Fax Number	:	360-895-7835

Provider Business Practice Location Address
First Line	:	450 S KITSAP BLVD
Second Line	:	SUITE 178
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-3773
Country	:	US
Telephone Number	:	360-895-7795
Fax Number	:	360-895-7835

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KATRINA ARDEL RUSSELL
Credential	:	RN, CNN
Telephone Number	:	206-915-9502

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	12/15/2009

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98366-3773

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1629057658 — DR. CHRISTOPHER S QUARLES MD
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1396793709 — THE DOCTORS CLINIC A PROFESSIONAL CORPORATION
Practice Location Address:

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Practice Location Address:

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1255380804 — DR. HECTOR DECENA REYES JR. MD
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Directions to “OLYMPIC PENINSULA KIDNEY CENTER ” Practice Location

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