Provider Demographics
NPI:1134280837
Name:PUGET SOUND MEDICAL
Entity Type:Organization
Organization Name:PUGET SOUND MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-857-3322
Mailing Address - Street 1:3202 20TH ST E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-1713
Mailing Address - Country:US
Mailing Address - Phone:253-284-0909
Mailing Address - Fax:253-284-0913
Practice Address - Street 1:10130 SW NIMBUS AVE STE D9
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-4335
Practice Address - Country:US
Practice Address - Phone:866-639-9501
Practice Address - Fax:503-639-9634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9774332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298962Medicaid
OR4782550002Medicare NSC