Provider Demographics
NPI:1467582320
Name:EASTSIDE HAND REHABILITATION CLINIC INC
Entity Type:Organization
Organization Name:EASTSIDE HAND REHABILITATION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNNLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLENWIDER
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL CHT
Authorized Official - Phone:425-823-1389
Mailing Address - Street 1:12911-120TH AVE NE
Mailing Address - Street 2:SUITE F-120
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3025
Mailing Address - Country:US
Mailing Address - Phone:425-823-1389
Mailing Address - Fax:425-820-3996
Practice Address - Street 1:12911-120TH AVE NE
Practice Address - Street 2:SUITE F-120
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3025
Practice Address - Country:US
Practice Address - Phone:425-823-1389
Practice Address - Fax:425-820-3996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAEA2218OtherREGENCE
WA7680697Medicaid
WAT06695OtherPREMERA
WA34460OtherL & I
WAEA2218OtherREGENCE
WAT06695OtherPREMERA
WA0523280001Medicare NSC