Provider Demographics
NPI:1245230598
Name:VANTAGE RADIOLOGY & DIAGNOSTIC SERVICES, A PROFESSIONAL SERVICES CORP
Entity Type:Organization
Organization Name:VANTAGE RADIOLOGY & DIAGNOSTIC SERVICES, A PROFESSIONAL SERVICES CORP
Other - Org Name:VALLEY MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-661-1700
Mailing Address - Street 1:PO BOX 26730
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98093-3730
Mailing Address - Country:US
Mailing Address - Phone:253-661-1700
Mailing Address - Fax:253-661-4565
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055
Practice Address - Country:US
Practice Address - Phone:425-251-5183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000159700OtherMEDICARE PROVIDER #