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General NPI Number Information
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NPI Number | 1245566843
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Entity Type | Organization
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Legal Business Name | SOUTHWEST PORTLAND MEDICAL CLINIC INC
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Dates
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Enumeration Date | 11/02/2009
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Last Update Date | 11/02/2009
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Provider Practice Location Address
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Address Line | 3716 PACIFIC AVE STE D
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City | TACOMA
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State | WA
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Zip | 98418-7836
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Country | US
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Telephone | 253-474-7719
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Fax |
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Provider Business Mailing Address
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Address Line | 6097 156TH PL SE
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City | BELLEVUE
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State | WA
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Zip | 98006-5307
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Country | US
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Telephone | 425-785-6164
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. FELINO BAUTISTA DE LEON III
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Credential | MD
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Telephone | 425-306-9447
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 00022250
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License Number State | WA
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