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General NPI Number Information
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NPI Number | 1215528732
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Entity Type | Organization
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Legal Business Name | NORTHWEST KETAMINE CLINICS TACOMA, PLLC
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Dates
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Enumeration Date | 01/27/2021
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Last Update Date | 01/27/2021
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Provider Practice Location Address
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Address Line | 1901 S UNION AVE BUILDING B, SUITE 4001
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City | TACOMA
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State | WA
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Zip | 98405
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Country | US
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Telephone | 206-309-2299
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Fax | 425-256-3250
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Provider Business Mailing Address
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Address Line | 35302 SE CENTER ST
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City | SNOQUALMIE
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State | WA
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Zip | 98065-9216
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Country | US
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Telephone | 206-330-6722
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Fax | 425-256-3250
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Authorized Official
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Title or Position | OWNER
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Name | ALLYN D WILCOCK
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Credential | ARNP
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Telephone | 206-330-6722
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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