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General NPI Number Information
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NPI Number | 1821237488
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE CLINIC DME
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Dates
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Enumeration Date | 02/05/2009
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Last Update Date | 05/17/2010
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Provider Practice Location Address
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Address Line | 4033 TALBOT RD S SUITE 500
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City | RENTON
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State | WA
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Zip | 98055-5772
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Country | US
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Telephone | 425-251-5110
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Fax | 425-793-7382
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Provider Business Mailing Address
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Address Line | PO BOX 59028
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City | RENTON
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State | WA
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Zip | 98058-2028
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Country | US
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Telephone | 425-251-5110
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Fax | 425-793-7458
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Authorized Official
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Title or Position | CHEIF OPERATING OFFICER
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Name | MARIANNE LARSON
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Credential |
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Telephone | 425-251-5110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 600 052 154
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License Number State | WA
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