Healthcare Provider Details

I. General information

NPI: 1649535642
Provider Name (Legal Business Name): WESTERN WASHINGTON MEDICAL GROUP INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 214TH ST SE SUITE 211
BOTHELL WA
98021-4412
US

IV. Provider business mailing address

1728 W MARINE VIEW DR
EVERETT WA
98201-2094
US

V. Phone/Fax

Practice location:
  • Phone: 425-259-4041
  • Fax:
Mailing address:
  • Phone: 425-259-4041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateWA

VIII. Authorized Official

Name: KIM HOLSTEIN
Title or Position: DIRECTOR PFS
Credential:
Phone: 425-259-4041