Provider Demographics
NPI:1417178559
Name:KLEENWELL MEDICAL SERVICE
Entity Type:Organization
Organization Name:KLEENWELL MEDICAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:ROWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DME
Authorized Official - Phone:206-433-0715
Mailing Address - Street 1:15411 4TH AVE SW
Mailing Address - Street 2:SUITE B
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2571
Mailing Address - Country:US
Mailing Address - Phone:206-433-0715
Mailing Address - Fax:206-241-0370
Practice Address - Street 1:15411 4TH AVE SW
Practice Address - Street 2:SUITE B
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2571
Practice Address - Country:US
Practice Address - Phone:206-433-0715
Practice Address - Fax:206-241-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9037789Medicaid
WA9037789Medicaid