Healthcare Provider Details

I. General information

NPI: 1578659678
Provider Name (Legal Business Name): IMKA LAVINDER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 PT FOSDICK DR NW #211
GIG HARBOR WA
98335
US

IV. Provider business mailing address

316 MARTIN LUTHER KING JR WAY #212
TACOMA WA
98405
US

V. Phone/Fax

Practice location:
  • Phone: 253-851-5665
  • Fax: 253-627-0855
Mailing address:
  • Phone: 253-383-5777
  • Fax: 253-627-0855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOP00001745
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: