Healthcare Provider Details

I. General information

NPI: 1568068609
Provider Name (Legal Business Name): CERTIFIED LAB SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3123 FAIRVIEW AVE E STE 200
SEATTLE WA
98102-3051
US

IV. Provider business mailing address

3123 FAIRVIEW AVE E STE 200
SEATTLE WA
98102-3051
US

V. Phone/Fax

Practice location:
  • Phone: 480-685-7530
  • Fax: 480-900-8853
Mailing address:
  • Phone: 480-685-7530
  • Fax: 480-900-8853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER A WALLACE
Title or Position: OWNER/ OPERATOR
Credential: MEDICAL ASSISTANT
Phone: 480-685-7530