=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841044377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2024
-----------------------------------------------------
Last Update Date | 05/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18904 HIGHWAY 99 STE F
-----------------------------------------------------
City | LYNNWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98036-5219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-255-1851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11700 MUKILTEO SPEEDWAY STE 201-1142
-----------------------------------------------------
City | MUKILTEO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98275-5432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-354-9335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SCOTT WARREN FETTY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 206-354-9335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------