Healthcare Provider Details

I. General information

NPI: 1548791924
Provider Name (Legal Business Name): SOUTHLAKE SELECT, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 TALBOT RD S 440
RENTON WA
98055-5773
US

IV. Provider business mailing address

4011 TALBOT RD S 440
RENTON WA
98055-5773
US

V. Phone/Fax

Practice location:
  • Phone: 425-793-4702
  • Fax: 425-271-5382
Mailing address:
  • Phone: 425-793-4702
  • Fax: 425-271-5382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number0020685
License Number StateWA

VIII. Authorized Official

Name: DR. DOMINICK ROBERT TOULOUSE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 425-793-4702