Healthcare Provider Details

I. General information

NPI: 1063661098
Provider Name (Legal Business Name): THE CAROL MILGARD BREAST CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 SOUTH 19TH STREET
TACOMA WA
98405-1106
US

IV. Provider business mailing address

PO BOX 1535
TACOMA WA
98401-1535
US

V. Phone/Fax

Practice location:
  • Phone: 253-761-4200
  • Fax: 253-761-4201
Mailing address:
  • Phone: 253-761-4200
  • Fax: 253-761-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIRSTEN MAXWELL
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 253-680-3564