Provider Demographics
NPI:1497874903
Name:PUYALLUP CLINIC INC
Entity Type:Organization
Organization Name:PUYALLUP CLINIC INC
Other - Org Name:PUYALLUP CLINIC INC., PS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:DURIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-845-6645
Mailing Address - Street 1:800 S MERIDIAN STE A
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-6994
Mailing Address - Country:US
Mailing Address - Phone:253-845-6645
Mailing Address - Fax:253-770-2295
Practice Address - Street 1:800 S MERIDIAN STE A
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-6994
Practice Address - Country:US
Practice Address - Phone:253-845-6645
Practice Address - Fax:253-770-2295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261Q00000X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7120363Medicaid
WA7120363Medicaid