Provider Demographics
NPI:1083868293
Name:ERICKSON LABORATORIES, INC
Entity Type:Organization
Organization Name:ERICKSON LABORATORIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OCULARIST
Authorized Official - Phone:206-622-9175
Mailing Address - Street 1:509 OLIVE WAY
Mailing Address - Street 2:SUITE 1421
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1749
Mailing Address - Country:US
Mailing Address - Phone:206-622-9175
Mailing Address - Fax:206-622-9378
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:SUITE 1421
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101
Practice Address - Country:US
Practice Address - Phone:206-622-9175
Practice Address - Fax:206-622-9378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WA601571019335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9111006Medicaid
WA1164380002Medicare NSC