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Organization
SOUTHLAKE CLINIC INC PS
Active
Organization
SOUTHLAKE CLINIC INC PS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARIANNE LARSON (DIRECTOR OF OPERATIONS)
(425) 251-5110
Entity
Organization
Contact information
Practice address
4011 TALBOT ROAD SOUTH, SUITE 500, RENTON, WA 98055
(425) 251-5110
(425) 793-4710
Mailing address
PO BOX 59028, RENTON, WA 98058-2028
(425) 251-5110
(425) 793-7458
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
FS.60293976
WA
261QE0800X
Endoscopy Clinic/Center
FS.60293976
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0119463
L&I
WA
01
—
490003337
RAILROAD MEDICARE
WA
05
—
7083660
—
WA
Enumeration date
01/08/2007
Last updated
11/20/2012
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