Organization
L A PROFESSIONAL SERVICE CORP.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TERRILYNN NICKLIN GRISWOLD (BILLING MANAGER)
(360) 434-3009
Entity
Organization
Contact information
Practice address
804 CALLAHAN DR # A, BREMERTON, WA 98310-3307
(360) 377-9744
(360) 377-2341
Mailing address
804 CALLAHAN DR # A, BREMERTON, WA 98310-3307
(360) 377-9744
(360) 377-2341
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
002495
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0075138
L&I
WA
05
—
1048636
—
WA
01
—
AF1655
REGENCE
WA
Enumeration date
11/07/2006
Last updated
08/22/2020
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