MEDICARE: AMNESIA LLC

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	207L00000X	Anesthesiology Physician

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	:	1922202688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMNESIA LLC

Provider Business Mailing Address
First Line	:	3819 100TH ST SW
Second Line	:	SUITE 7C
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-4470
Country	:	US
Telephone Number	:	253-588-7911
Fax Number	:

Provider Business Practice Location Address
First Line	:	4717 S 19TH ST
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98405-1167
Country	:	US
Telephone Number	:	253-761-0861
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BROCK M SMITH
Credential	:	CRNA, ARNP
Telephone Number	:	360-753-3516

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	08/22/2020

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Directions to “AMNESIA LLC ” Practice Location

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