Healthcare Provider Details

I. General information

NPI: 1043368426
Provider Name (Legal Business Name): SOUTHLAKE CLINIC INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 TALBOT ROAD SOUTH SUITE 500
RENTON WA
98055
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 TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License NumberFS.60293976
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberFS.60293976
License Number StateWA

VIII. Authorized Official

Name: MARIANNE LARSON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 425-251-5110