Healthcare Provider Details

I. General information

NPI: 1538566161
Provider Name (Legal Business Name): COLLINS KENNETH FREITAS C.PED.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 12TH AVE NE
OLYMPIA WA
98506-5218
US

IV. Provider business mailing address

3508 12TH AVE NE
OLYMPIA WA
98506-5218
US

V. Phone/Fax

Practice location:
  • Phone: 360-459-1099
  • Fax: 360-459-1794
Mailing address:
  • Phone: 360-459-1099
  • Fax: 360-459-1794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: