Provider Demographics
NPI:1114540457
Name:COUNTRY DOCTOR COMMUNITY CLINIC
Entity Type:Organization
Organization Name:COUNTRY DOCTOR COMMUNITY CLINIC
Other - Org Name:NOVA WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REVENUE AND REIMBURSEMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:TREPTOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-299-1937
Mailing Address - Street 1:2410 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4832
Mailing Address - Country:US
Mailing Address - Phone:206-299-1900
Mailing Address - Fax:206-299-1920
Practice Address - Street 1:2410 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4832
Practice Address - Country:US
Practice Address - Phone:206-299-1900
Practice Address - Fax:206-299-1920
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTRY DOCTOR COMMUNITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-21
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty