Organization
SOUTHLAKE CLINIC INC PS
Active
Other names
Southlake Clinic Pathology
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MARIANNE LARSON (COO)
(425) 251-5110
Entity
Organization
Contact information
Practice address
4011 TALBOT RD S, SUITE 500, RENTON, WA 98055-5773
(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
207ZP0101X
Anatomic Pathology Physician
Primary
MD00015542
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0057600
DEPT OF L&I
WA
05
—
7147564
—
WA
Enumeration date
05/26/2009
Last updated
08/06/2012
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