Organization
104TH AVENUE MEDICAL CLINIC INCORPORATED
Active
Organization
104TH AVENUE MEDICAL CLINIC INCORPORATED
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RANU CHOUDHARY M.D. (VICE-PRESIDENT)
(253) 859-8371
Entity
Organization
Contact information
Practice address
24604 104TH AVE SE, # 202, KENT, WA 98030-5385
(253) 859-8371
(253) 859-9593
Mailing address
24604 104TH AVE SE, # 202, KENT, WA 98030-5385
(253) 859-8371
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
37861
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1110378
—
WA
Enumeration date
01/22/2008
Last updated
10/01/2014
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