Provider Demographics
NPI:1225257363
Name:WEST OLYMPIA FAMILY MEDICINE INC, PC
Entity Type:Organization
Organization Name:WEST OLYMPIA FAMILY MEDICINE INC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:WELLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-754-4837
Mailing Address - Street 1:1401 MARVIN RD NE STE 307 PMB 266
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5710
Mailing Address - Country:US
Mailing Address - Phone:360-491-5055
Mailing Address - Fax:360-491-5890
Practice Address - Street 1:402 BLACK HILLS LN SW STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8146
Practice Address - Country:US
Practice Address - Phone:360-754-4837
Practice Address - Fax:360-754-7304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124098Medicaid
WA=========OtherTIN
WA=========OtherTIN