Healthcare Provider Details

I. General information

NPI: 1376306852
Provider Name (Legal Business Name): EAR NOSE AND THROAT ASSOCIATES SOUTHWEST INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 LILLY RD NE STE 202
OLYMPIA WA
98506-7400
US

IV. Provider business mailing address

128 LILLY RD NE STE 202
OLYMPIA WA
98506-7400
US

V. Phone/Fax

Practice location:
  • Phone: 360-357-6314
  • Fax: 360-705-3745
Mailing address:
  • Phone: 360-357-6314
  • Fax: 360-705-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUNG-WON KIM
Title or Position: CEO
Credential: MD
Phone: 360-357-6314