Provider Demographics
NPI:1467470914
Name:OLYMPIC DERMATOLOGY AND LASER CLINIC P S
Entity Type:Organization
Organization Name:OLYMPIC DERMATOLOGY AND LASER CLINIC P S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LENNAE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-459-1700
Mailing Address - Street 1:424 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5132
Mailing Address - Country:US
Mailing Address - Phone:360-459-1700
Mailing Address - Fax:360-459-0537
Practice Address - Street 1:424 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5132
Practice Address - Country:US
Practice Address - Phone:360-459-1700
Practice Address - Fax:360-459-0537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8801740Medicare PIN