MEDICARE: DYNACARE NORTHWEST, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50D0925501	OTHER		CLIA

General Provider Information

NPI Number	:	1649426883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNACARE NORTHWEST, INC

Provider Business Mailing Address
First Line	:	PO BOX 2240
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27216-2240
Country	:	US
Telephone Number	:	800-222-7566
Fax Number	:

Provider Business Practice Location Address
First Line	:	275 SE CABOT DR STE B202
Second Line	:
City	:	OAK HARBOR
State	:	WA
Zip	:	98277-3755
Country	:	US
Telephone Number	:	360-675-5133
Fax Number	:

Authorized Official
Title or Position	:	CFO EVP TREASURER
Name	:	MR. WILLIAM B HAYES
Credential	:
Telephone Number	:	800-222-7566

Provider Enumeration Date	:	08/07/2008
Last Update Date	:	08/07/2008

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