MEDICARE: NORTHWEST VASCULAR LAB PLLC

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	293D00000X	Physiological Laboratory	4363	WA

General Provider Information

NPI Number	:	1154438000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST VASCULAR LAB PLLC

Provider Business Mailing Address
First Line	:	3104 SQUALICUM PKWY
Second Line	:	SUITE 101
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-1936
Country	:	US
Telephone Number	:	360-733-8128
Fax Number	:	360-733-5354

Provider Business Practice Location Address
First Line	:	3104 SQUALICUM PKWY
Second Line	:	SUITE 101
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-1936
Country	:	US
Telephone Number	:	360-733-8128
Fax Number	:	360-733-5354

Authorized Official
Title or Position	:	TECHNICAL DIRECTOR
Name	:	JOHN OBRIEN
Credential	:	RVT
Telephone Number	:	360-733-8128

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	01/04/2012

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