# SOUTH SOUND FAMILY & SPORTS

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

## Provider details

- **NPI number:** 1558446211
- **Authorized official:** MRS. JENNY A BLAKE (OPS MANAGER)
- **Authorized official phone:** (360) 709-9500

## Contact information

- **Practice address:** 2960-A LIMITED LANE NW, OLYMPIA, WA 98502-4541
- **Practice address phone:** (360) 709-9500
- **Practice address fax:** (360) 754-4517
- **Mailing address:** 2960 LIMITED LN NW STE A, OLYMPIA, WA 98502-4541
- **Mailing address phone:** (360) 709-9500
- **Mailing address fax:** (360) 754-4517

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 602369889 | WA | Yes |

## Other

- **Enumeration date:** 10/25/2006
- **Last updated:** 07/10/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 50D1031645 | CLIA | — |
| 01 | — | 7122450 | DSHS | — |
| 01 | — | O186019 | L & I | — |