Healthcare Provider Details

I. General information

NPI: 1174934707
Provider Name (Legal Business Name): NW MAGNUM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 CENTRAL WAY
KIRKLAND WA
98033-6106
US

IV. Provider business mailing address

108 CENTRAL WAY
KIRKLAND WA
98033-6106
US

V. Phone/Fax

Practice location:
  • Phone: 425-576-0021
  • Fax:
Mailing address:
  • Phone: 425-576-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPANDING
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPANDING
License Number State

VIII. Authorized Official

Name: RUSLAN R KNYAZ
Title or Position: CEO
Credential:
Phone: 425-576-0021