Healthcare Provider Details

I. General information

NPI: 1003985060
Provider Name (Legal Business Name): OVERLAKE BREAST IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 116TH AVE NE SUITE 255
BELLEVUE WA
98004
US

IV. Provider business mailing address

19401 40TH AVE WEST SUITE 140
LYNNWOOD WA
98036-4612
US

V. Phone/Fax

Practice location:
  • Phone: 425-467-3754
  • Fax: 425-213-1336
Mailing address:
  • Phone: 425-771-8161
  • Fax: 425-771-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateWA

VIII. Authorized Official

Name: MARK P JONES
Title or Position: CO-MANAGER
Credential:
Phone: 425-771-8161