Healthcare Provider Details

I. General information

NPI: 1073573820
Provider Name (Legal Business Name): OLYMPIA OPEN MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 WOODLAND SQUARE LOOP SE STE D
LACEY WA
98503-1038
US

IV. Provider business mailing address

10151 SW BARBUR BLVD STE 105D
PORTLAND OR
97219-5911
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-9393
  • Fax: 360-413-9365
Mailing address:
  • Phone: 503-246-2808
  • Fax: 503-246-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN MICHAEL GOLDEN
Title or Position: MANAGING MEMBER
Credential:
Phone: 503-246-2808