Provider Demographics
NPI:1093835811
Name:PUGET SOUND KIDNEY CENTERS
Entity Type:Organization
Organization Name:PUGET SOUND KIDNEY CENTERS
Other - Org Name:PSKC - SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-5195
Mailing Address - Street 1:1005 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4148
Mailing Address - Country:US
Mailing Address - Phone:425-259-5195
Mailing Address - Fax:425-259-4890
Practice Address - Street 1:21309 44TH AVE W
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-3507
Practice Address - Country:US
Practice Address - Phone:425-744-1095
Practice Address - Fax:425-775-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3144805Medicaid
WA3144805Medicaid