Healthcare Provider Details

I. General information

NPI: 1982791349
Provider Name (Legal Business Name): BALLINGER CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6007B 244TH ST SW
MOUNTLAKE TERRACE WA
98043-5400
US

IV. Provider business mailing address

6007B 244TH ST SW
MOUNTLAKE TERRACE WA
98043-5400
US

V. Phone/Fax

Practice location:
  • Phone: 425-640-4830
  • Fax: 425-640-4885
Mailing address:
  • Phone: 425-640-4830
  • Fax: 425-640-4885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateWA

VIII. Authorized Official

Name: ROCKY WILLIAM MAZZEO
Title or Position: OWNER PARTNER
Credential: MD
Phone: 425-640-4830