Healthcare Provider Details

I. General information

NPI: 1033238472
Provider Name (Legal Business Name): NORTHWEST CLINICAL NUTRITION CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 NE 125TH ST STE 90 SUITE 208
SEATTLE WA
98125-4357
US

IV. Provider business mailing address

2611 NE 125TH ST STE 90
SEATTLE WA
98125-4357
US

V. Phone/Fax

Practice location:
  • Phone: 206-362-0035
  • Fax: 206-362-6927
Mailing address:
  • Phone: 206-592-5000
  • Fax: 206-824-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number6006101999
License Number StateWA

VIII. Authorized Official

Name: DR. ROBERT A KANTER
Title or Position: DIRECTOR
Credential: MD
Phone: 206-362-0035