# OVER LAKE MEDICAL CENTER

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

## Provider details

- **NPI number:** 1770971830
- **Authorized official:** KIER JORDAN-KEITH (PRACTICE SUPERVISOR)
- **Authorized official phone:** (425) 688-5846

## Contact information

- **Practice address:** 1750 112TH AVE NE, SUITE A101, BELLEVUE, WA 98004-3752
- **Practice address phone:** (425) 688-5234
- **Mailing address:** 1750 112TH AVE NE, SUITE A101, BELLEVUE, WA 98004-3752
- **Mailing address phone:** (425) 688-5234

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | AP60481748 | WA | Yes |

## Other

- **Enumeration date:** 12/24/2014
- **Last updated:** 12/24/2014