Provider Demographics
NPI:1003809229
Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Other - Org Name:LAKE SERENE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:DON
Authorized Official - Last Name:FRIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-742-9119
Mailing Address - Street 1:3501 SHELBY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-3599
Mailing Address - Country:US
Mailing Address - Phone:425-742-9119
Mailing Address - Fax:
Practice Address - Street 1:3501 SHELBY RD
Practice Address - Street 2:SUITE B
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-3599
Practice Address - Country:US
Practice Address - Phone:425-742-9119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care