Healthcare Provider Details

I. General information

NPI: 1548667330
Provider Name (Legal Business Name): OLGA KLACHKOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2014
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NE GILMAN BLVD
ISSAQUAH WA
98027-2925
US

IV. Provider business mailing address

1100 9TH AVE M4-PFS
SEATTLE WA
98101-2756
US

V. Phone/Fax

Practice location:
  • Phone: 425-557-8000
  • Fax: 425-557-8014
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberPA60608537
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: