Organization
SOUTHLAKE CLINIC DME
Active
Parent organization
SOUTHLAKE CLINIC, INC., P.S.
Organization subpart
Yes
Provider details
NPI number
Legal business name
SOUTHLAKE CLINIC, INC., P.S.
Authorized official
MARIANNE LARSON (CHEIF OPERATING OFFICER)
(425) 251-5110
Entity
Organization
Contact information
Practice address
4033 TALBOT RD S, SUITE 500, RENTON, WA 98055-5772
(425) 251-5110
(425) 793-7382
Mailing address
PO BOX 59028, RENTON, WA 98058-2028
(425) 251-5110
(425) 793-7458
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
600 052 154
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9062571
—
WA
Enumeration date
02/05/2009
Last updated
05/17/2010
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