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General NPI Number Information
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NPI Number | 1346518925
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Entity Type | Organization
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Legal Business Name | INNOVATIVE CARE CLINIC
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Dates
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Enumeration Date | 12/09/2011
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Last Update Date | 12/09/2011
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Provider Practice Location Address
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Address Line | 1700 132ND ST SE SUITE L
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City | MILL CREEK
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State | WA
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Zip | 98012-5309
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Country | US
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Telephone | 425-338-1555
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Fax | 425-338-0765
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Provider Business Mailing Address
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Address Line | 1700 132ND ST SE SUITE L
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City | MILL CREEK
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State | WA
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Zip | 98012-5309
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Country | US
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Telephone | 425-338-1555
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Fax | 425-338-0765
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. FERNANDA VELDERRAIN
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Credential |
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Telephone | 425-338-1555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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