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General NPI Number Information
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NPI Number | 1952057770
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Entity Type | Organization
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Legal Business Name | HEART CLINIC OF TACOMA
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Dates
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Enumeration Date | 03/02/2022
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Last Update Date | 03/02/2022
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Provider Practice Location Address
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Address Line | 120 STATE AVE NE #122
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City | OLYMPIA
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State | WA
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Zip | 98501
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Country | US
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Telephone | 253-279-3487
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Fax |
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Provider Business Mailing Address
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Address Line | 120 STATE AVE NE #122
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City | OLYMPIA
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State | WA
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Zip | 98501
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Country | US
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Telephone | 253-279-3487
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DENNIS CHARLES KOUKOL
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Credential | M.D.
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Telephone | 253-279-3487
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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