Healthcare Provider Details

I. General information

NPI: 1366657918
Provider Name (Legal Business Name): THE IDA KARLIN PEDIATRIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 5TH ST SW
PUYALLUP WA
98371-5828
US

IV. Provider business mailing address

319 5TH ST SW
PUYALLUP WA
98371-5828
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-0351
  • Fax: 253-841-1397
Mailing address:
  • Phone: 253-848-0351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP60312846
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60311598
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLH60394287
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY60385056
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00015660
License Number StateWA

VIII. Authorized Official

Name: OVIDIO PENALVER
Title or Position: CORPORATE OFFICER, PROVIDER
Credential: MD
Phone: 253-848-0351