Healthcare Provider Details

I. General information

NPI: 1104216860
Provider Name (Legal Business Name): BETH LUDLOW LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETH LUDLOW

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13200 HADFIELD RD SE
OLALLA WA
98359-9540
US

IV. Provider business mailing address

13200 HADFIELD RD SE
OLALLA WA
98359-9540
US

V. Phone/Fax

Practice location:
  • Phone: 253-678-6118
  • Fax:
Mailing address:
  • Phone: 253-678-6118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA60487445
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: