=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376156620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLYMPIA ALLERGY AND IMMUNOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2020
-----------------------------------------------------
Last Update Date | 12/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2320 130TH AVE NE STE 220
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98005-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-754-0257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2320 130TH AVE NE STE 220
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98005-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | JON ERIC WELCH
-----------------------------------------------------
Credential | MD, PHD
-----------------------------------------------------
Telephone | 704-754-0257
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0201X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------