Healthcare Provider Details

I. General information

NPI: 1538394234
Provider Name (Legal Business Name): SOUTHLAKE CLINIC INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 TALBOT RD S SUITE 500
RENTON WA
98055-5773
US

IV. Provider business mailing address

PO BOX 59028
RENTON WA
98058-2028
US

V. Phone/Fax

Practice location:
  • Phone: 425-251-5110
  • Fax: 425-793-4710
Mailing address:
  • Phone: 425-251-5110
  • Fax: 425-793-7458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD00015542
License Number StateWA

VIII. Authorized Official

Name: MS. MARIANNE LARSON
Title or Position: COO
Credential:
Phone: 425-251-5110