Healthcare Provider Details

I. General information

NPI: 1023281623
Provider Name (Legal Business Name): ENUMCLAW INTERNAL MEDICINE AND DIAGNOSTICS, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 JEFFERSON AVE SUITE # 102
ENUMCLAW WA
98022-3649
US

IV. Provider business mailing address

1427 JEFFERSON AVE SUITE # 102
ENUMCLAW WA
98022-3649
US

V. Phone/Fax

Practice location:
  • Phone: 360-802-0803
  • Fax: 360-802-0806
Mailing address:
  • Phone: 360-802-0803
  • Fax: 360-802-0806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: EMITIS K HOSODA
Title or Position: PRESIDENT
Credential:
Phone: 360-802-0803