Healthcare Provider Details

I. General information

NPI: 1770826901
Provider Name (Legal Business Name): MGA MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2013
Last Update Date: 04/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 TACOMA AVE
SUNNYSIDE WA
98944-2263
US

IV. Provider business mailing address

250 GAGE BLVD #2121
RICHLAND WA
99352-9605
US

V. Phone/Fax

Practice location:
  • Phone: 509-837-1500
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number00046318
License Number StateWA

VIII. Authorized Official

Name: LORI LABRECQUE
Title or Position: ACCTS MGR
Credential:
Phone: 702-453-3799