Healthcare Provider Details

I. General information

NPI: 1598982324
Provider Name (Legal Business Name): THE CLINIC AT PANORAMA CITY,PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4044 15TH LN SE SUITE A
LACEY WA
98503
US

IV. Provider business mailing address

4044 15TH LN SE SUITE A
LACEY WA
98503
US

V. Phone/Fax

Practice location:
  • Phone: 360-491-4460
  • Fax: 360-491-3090
Mailing address:
  • Phone: 360-491-4460
  • Fax: 360-491-3090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID L FAIRBROOK
Title or Position: OWNER
Credential: MD
Phone: 360-491-4460