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General NPI Number Information
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NPI Number | 1043368426
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE CLINIC INC PS
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 11/20/2012
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Provider Practice Location Address
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Address Line | 4011 TALBOT ROAD SOUTH SUITE 500
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City | RENTON
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State | WA
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Zip | 98055
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Country | US
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Telephone | 425-251-5110
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Fax | 425-793-4710
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Provider Business Mailing Address
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Address Line | PO BOX 59028
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City | RENTON
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State | WA
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Zip | 98058-2028
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Country | US
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Telephone | 425-251-5110
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Fax | 425-793-7458
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | MARIANNE LARSON
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Credential |
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Telephone | 425-251-5110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0800X
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Taxonomy Name | Endoscopy Clinic/Center
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License Number | FS.60293976
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | FS.60293976
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License Number State | WA
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