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General NPI Number Information
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NPI Number | 1770971830
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Entity Type | Organization
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Legal Business Name | OVER LAKE MEDICAL CENTER
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Dates
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Enumeration Date | 12/24/2014
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Last Update Date | 12/24/2014
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Provider Practice Location Address
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Address Line | 1750 112TH AVE NE SUITE A101
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City | BELLEVUE
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State | WA
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Zip | 98004-3752
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Country | US
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Telephone | 425-688-5234
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Fax |
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Provider Business Mailing Address
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Address Line | 1750 112TH AVE NE SUITE A101
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City | BELLEVUE
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State | WA
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Zip | 98004-3752
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Country | US
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Telephone | 425-688-5234
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Fax |
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Authorized Official
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Title or Position | PRACTICE SUPERVISOR
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Name | KIER JORDAN-KEITH
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Credential |
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Telephone | 425-688-5846
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | AP60481748
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License Number State | WA
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