Provider Demographics
NPI:1346518925
Name:INNOVATIVE CARE CLINIC
Entity Type:Organization
Organization Name:INNOVATIVE CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FERNANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VELDERRAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-338-1555
Mailing Address - Street 1:1700 132ND ST SE
Mailing Address - Street 2:SUITE L
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-5309
Mailing Address - Country:US
Mailing Address - Phone:425-338-1555
Mailing Address - Fax:425-338-0765
Practice Address - Street 1:1700 132ND ST SE
Practice Address - Street 2:SUITE L
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-5309
Practice Address - Country:US
Practice Address - Phone:425-338-1555
Practice Address - Fax:425-338-0765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0287152OtherLABOR AND INDUSTRIES