Provider Demographics
NPI:1508134792
Name:CONCORDIA STAR MEDICAL LLC
Entity Type:Organization
Organization Name:CONCORDIA STAR MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LADIE
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:ARANA-DOMONDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-209-9009
Mailing Address - Street 1:118 7TH AVE SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-6803
Mailing Address - Country:US
Mailing Address - Phone:253-579-0067
Mailing Address - Fax:253-579-0068
Practice Address - Street 1:118 7TH AVE SW
Practice Address - Street 2:SUITE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-6803
Practice Address - Country:US
Practice Address - Phone:253-579-0067
Practice Address - Fax:253-579-0068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034362261QM1300X, 261QP2300X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care