Provider Demographics
NPI:1417577909
Name:UP FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:UP FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVALOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-564-8100
Mailing Address - Street 1:4114 BRIDGEPORT WAY W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4315
Mailing Address - Country:US
Mailing Address - Phone:253-564-8100
Mailing Address - Fax:253-564-8387
Practice Address - Street 1:4114 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4315
Practice Address - Country:US
Practice Address - Phone:253-564-8100
Practice Address - Fax:253-564-8387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service