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General NPI Number Information
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NPI Number | 1548791924
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE SELECT, PC
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Dates
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Enumeration Date | 03/27/2017
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Last Update Date | 05/08/2017
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Provider Practice Location Address
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Address Line | 4011 TALBOT RD S 440
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City | RENTON
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State | WA
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Zip | 98055-5773
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Country | US
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Telephone | 425-793-4702
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Fax | 425-271-5382
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Provider Business Mailing Address
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Address Line | 4011 TALBOT RD S 440
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City | RENTON
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State | WA
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Zip | 98055-5773
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Country | US
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Telephone | 425-793-4702
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Fax | 425-271-5382
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DOMINICK ROBERT TOULOUSE
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Credential | M.D.
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Telephone | 425-793-4702
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 0020685
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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