MEDICARE: NORTHWEST CLINICAL NUTRITION CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	6006101999	WA

General Provider Information

NPI Number	:	1033238472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST CLINICAL NUTRITION CENTER INC

Provider Business Mailing Address
First Line	:	2611 NE 125TH ST STE 90
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-4357
Country	:	US
Telephone Number	:	206-592-5000
Fax Number	:	206-824-9510

Provider Business Practice Location Address
First Line	:	2611 NE 125TH ST STE 90
Second Line	:	SUITE 208
City	:	SEATTLE
State	:	WA
Zip	:	98125-4357
Country	:	US
Telephone Number	:	206-362-0035
Fax Number	:	206-362-6927

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. ROBERT A KANTER
Credential	:	MD
Telephone Number	:	206-362-0035

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	04/06/2015

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