Organization
LAKE WILDERNESS MEDICAL CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHESTER E JANGALA JR. MD (PHYSICIAN)
(425) 432-9611
Entity
Organization
Contact information
Practice address
26907 MAPLE VALLEY BLACK DIAMOND RD SE, MAPLE VALLEY, WA 98038-8314
(425) 432-9611
(206) 973-5399
Mailing address
PO BOX 1142, RAVENSDALE, WA 98051-1142
(425) 432-9611
(206) 973-5399
Taxonomy
Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
Primary
MD00023662
WA
Other
Enumeration date
04/29/2008
Last updated
04/29/2008
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