=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538394234
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHLAKE CLINIC INC PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2009
-----------------------------------------------------
Last Update Date | 08/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4011 TALBOT RD S SUITE 500
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98055-5773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-251-5110
-----------------------------------------------------
Fax | 425-793-4710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 59028
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98058-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-251-5110
-----------------------------------------------------
Fax | 425-793-7458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MS. MARIANNE LARSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-251-5110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0101X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology Physician
-----------------------------------------------------
License Number | MD00015542
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------