# SOUTHLAKE CLINIC INC PS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1043368426
- **Authorized official:** MARIANNE LARSON (DIRECTOR OF OPERATIONS)
- **Authorized official phone:** (425) 251-5110

## Contact information

- **Practice address:** 4011 TALBOT ROAD SOUTH, SUITE 500, RENTON, WA 98055
- **Practice address phone:** (425) 251-5110
- **Practice address fax:** (425) 793-4710
- **Mailing address:** PO BOX 59028, RENTON, WA 98058-2028
- **Mailing address phone:** (425) 251-5110
- **Mailing address fax:** (425) 793-7458

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | FS.60293976 | WA | Yes |
| 261QE0800X | Endoscopy Clinic/Center | FS.60293976 | WA | — |

## Other

- **Enumeration date:** 01/08/2007
- **Last updated:** 11/20/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0119463 | L&I | WA |
| 01 | — | 490003337 | RAILROAD MEDICARE | WA |
| 05 | — | 7083660 | — | WA |