Provider Demographics
NPI:1073573820
Name:OLYMPIA OPEN MRI LLC
Entity Type:Organization
Organization Name:OLYMPIA OPEN MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-246-2808
Mailing Address - Street 1:10151 SW BARBUR BLVD
Mailing Address - Street 2:STE 105D
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5911
Mailing Address - Country:US
Mailing Address - Phone:503-246-2808
Mailing Address - Fax:503-246-2681
Practice Address - Street 1:669 WOODLAND SQUARE LOOP SE
Practice Address - Street 2:STE D
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1038
Practice Address - Country:US
Practice Address - Phone:360-413-9393
Practice Address - Fax:360-413-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7200116Medicaid
WA7200116Medicaid