MEDICARE: SOUTH SOUND FAMILY & SPORTS

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	207Q00000X	Family Medicine Physician	602369889	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	7122450	OTHER	DSHS
2	50D1031645	OTHER	CLIA
3	O186019	OTHER	L & I

General Provider Information

NPI Number	:	1558446211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SOUND FAMILY & SPORTS

Provider Business Mailing Address
First Line	:	2960 LIMITED LN NW STE A
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-4541
Country	:	US
Telephone Number	:	360-709-9500
Fax Number	:	360-754-4517

Provider Business Practice Location Address
First Line	:	2960-A LIMITED LANE NW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-4541
Country	:	US
Telephone Number	:	360-709-9500
Fax Number	:	360-754-4517

Authorized Official
Title or Position	:	OPS MANAGER
Name	:	MRS. JENNY A BLAKE
Credential	:
Telephone Number	:	360-709-9500

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/10/2012

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Directions to “SOUTH SOUND FAMILY & SPORTS ” Practice Location

Language	Start Address	Practice Location

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