Healthcare Provider Details

I. General information

NPI: 1376683946
Provider Name (Legal Business Name): GOOD SAMARITAN OUTREACH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 15TH AVE SE
PUYALLUP WA
98372-3709
US

IV. Provider business mailing address

325 E PIONEER
PUYALLUP WA
98372-3265
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-5200
  • Fax: 253-697-8598
Mailing address:
  • Phone: 253-697-8548
  • Fax: 253-697-8598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RONALD J LEWIS
Title or Position: VICE PRESIDENT
Credential:
Phone: 253-697-8500