Healthcare Provider Details

I. General information

NPI: 1548222102
Provider Name (Legal Business Name): LAKE FOREST PARK CLINIC TR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17191 BOTHELL WAY NE
LAKE FOREST PARK WA
98155-5534
US

IV. Provider business mailing address

17191 BOTHELL WAY NE SUITE 205
LAKE FOREST PARK WA
98155-5534
US

V. Phone/Fax

Practice location:
  • Phone: 206-365-6768
  • Fax: 206-364-5418
Mailing address:
  • Phone: 206-365-6768
  • Fax: 206-364-5418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHARLES WILLIAM SCHNEIDER
Title or Position: PRES/CEO
Credential:
Phone: 206-368-1700