Healthcare Provider Details

I. General information

NPI: 1548319171
Provider Name (Legal Business Name): SOUTHLAKE CLINIC INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 TALBOT ROAD SOUTH SUITE 300
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: 425-226-9085
Mailing address:
  • Phone: 425-251-5110
  • Fax: 425-793-4707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number600052154
License Number StateWA

VIII. Authorized Official

Name: MARIANNE LARSON
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 425-251-5110