Healthcare Provider Details

I. General information

NPI: 1720430903
Provider Name (Legal Business Name): WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 07/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3822 COLBY AVE SUITE 100
EVERETT WA
98201-4913
US

IV. Provider business mailing address

1728 W MARINE VIEW DR SUITE 110
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 Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

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