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General NPI Number Information
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NPI Number | 1205164639
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Entity Type | Organization
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Legal Business Name | MARANATHA MEDICAL CLINIC INC P S
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Dates
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Enumeration Date | 11/23/2009
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Last Update Date | 09/11/2017
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Provider Practice Location Address
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Address Line | 17900 TALBOT RD S #101
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City | RENTON
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State | WA
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Zip | 98055-8212
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Country | US
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Telephone | 425-235-9614
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Fax | 425-235-1060
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Provider Business Mailing Address
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Address Line | 17900 TALBOT RD S #101
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City | RENTON
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State | WA
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Zip | 98055-8212
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Country | US
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Telephone | 425-235-9614
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Fax | 425-235-1060
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DAN L GRAV ES
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Credential | MD
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Telephone | 425-235-9614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 17917
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License Number State | WA
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