=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952659393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST PHYSICIANS LABORATORIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2012
-----------------------------------------------------
Last Update Date | 08/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2840 NORTHUP WAY SUITE 100
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-563-6263
-----------------------------------------------------
Fax | 425-642-8078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2800 NORTHUP WAY SUITE 120
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-563-6263
-----------------------------------------------------
Fax | 425-642-8078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MR. JAE LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-563-6263
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 50D2040375
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------