Healthcare Provider Details

I. General information

NPI: 1922037696
Provider Name (Legal Business Name): OVERLAKE REPRODUCTIVE HEALTH LAB AND SURGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 116TH AVE NE SUITE 640
BELLEVUE WA
98004-4623
US

IV. Provider business mailing address

PO BOX 13684
SEATTLE WA
98198-1010
US

V. Phone/Fax

Practice location:
  • Phone: 425-646-4700
  • Fax: 425-646-1076
Mailing address:
  • Phone: 425-646-4700
  • Fax: 425-646-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN M JOHNSON
Title or Position: OWNER
Credential: M.D.
Phone: 425-646-4700