Healthcare Provider Details

I. General information

NPI: 1801828421
Provider Name (Legal Business Name): OVERLAKE MEDICAL CLINICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 116TH AVE NE SUITE 110
BELLEVUE WA
98004
US

IV. Provider business mailing address

PO BOX 3947 MS 315010
SEATTLE WA
98124-3947
US

V. Phone/Fax

Practice location:
  • Phone: 425-688-5670
  • Fax: 425-688-5124
Mailing address:
  • Phone: 425-688-5670
  • Fax: 425-688-5139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID SCHULTZ
Title or Position: COO
Credential:
Phone: 425-688-5470