Provider Demographics
NPI:1073757019
Name:DIGESTIVE DISEASE & ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:DIGESTIVE DISEASE & ENDOSCOPY CENTER, LLC
Other - Org Name:DIGESTIVE DISEASE & ENDOSCOPY CENTER, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:360-479-1952
Mailing Address - Street 1:3261 NW MOUNT VINTAGE WAY STE 221
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-6039
Mailing Address - Country:US
Mailing Address - Phone:360-479-1952
Mailing Address - Fax:360-479-0318
Practice Address - Street 1:3261 NW MOUNT VINTAGE WAY STE 221
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-6039
Practice Address - Country:US
Practice Address - Phone:360-479-1952
Practice Address - Fax:360-479-1952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty