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General NPI Number Information
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NPI Number | 1760551410
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Entity Type | Organization
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Legal Business Name | L A PROFESSIONAL SERVICE CORP.
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 804 CALLAHAN DR # A
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City | BREMERTON
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State | WA
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Zip | 98310-3307
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Country | US
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Telephone | 360-377-9744
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Fax | 360-377-2341
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Provider Business Mailing Address
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Address Line | 804 CALLAHAN DR # A
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City | BREMERTON
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State | WA
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Zip | 98310-3307
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Country | US
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Telephone | 360-377-9744
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Fax | 360-377-2341
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | TERRILYNN NICKLIN GRISWOLD
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Credential |
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Telephone | 360-434-3009
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 002495
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License Number State | WA
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