Healthcare Provider Details

I. General information

NPI: 1831274471
Provider Name (Legal Business Name): PORT HADLOCK MEDICAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 OAK BAY RD
PORT HADLOCK WA
98339-8718
US

IV. Provider business mailing address

PO BOX 1208
PORT HADLOCK WA
98339-1208
US

V. Phone/Fax

Practice location:
  • Phone: 360-379-6737
  • Fax: 360-379-6518
Mailing address:
  • Phone: 360-379-6737
  • Fax: 360-379-6518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. PEG CARLYLE CARLSON
Title or Position: OWNER
Credential:
Phone: 360-379-6737