Healthcare Provider Details

I. General information

NPI: 1699914226
Provider Name (Legal Business Name): 633
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7244 237TH AVE NE
REDMOND WA
98053-7914
US

IV. Provider business mailing address

7244 237TH AVE NE
REDMOND WA
98053-7914
US

V. Phone/Fax

Practice location:
  • Phone: 426-868-1178
  • Fax:
Mailing address:
  • Phone: 426-868-1178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License NumberRN 0007 3053
License Number StateWA

VIII. Authorized Official

Name: SHIRLEY CARRILLO
Title or Position: RN
Credential:
Phone: 425-868-1178