Provider Demographics
NPI:1518343516
Name:YOUGLYCEMIC DIABETES TREATMENT & PREVENTION
Entity Type:Organization
Organization Name:YOUGLYCEMIC DIABETES TREATMENT & PREVENTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-248-6414
Mailing Address - Street 1:2103 S 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98903-2412
Mailing Address - Country:US
Mailing Address - Phone:509-248-6414
Mailing Address - Fax:509-248-6408
Practice Address - Street 1:3902 CREEKSIDE LOOP
Practice Address - Street 2:SUITE 105
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4876
Practice Address - Country:US
Practice Address - Phone:509-248-6414
Practice Address - Fax:509-248-6408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty