Provider Demographics
NPI:1548210255
Name:OLYMPIC PENINSULA KIDNEY CENTER
Entity Type:Organization
Organization Name:OLYMPIC PENINSULA KIDNEY CENTER
Other - Org Name:OLYMPIC PENINSULA KIDNEY CENTER NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:ARDEL
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CNN
Authorized Official - Phone:206-915-9502
Mailing Address - Street 1:19472 POWDER HILL PL NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7473
Mailing Address - Country:US
Mailing Address - Phone:360-598-9712
Mailing Address - Fax:360-598-9716
Practice Address - Street 1:19472 POWDER HILL PL NE
Practice Address - Street 2:SUITE 100
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7473
Practice Address - Country:US
Practice Address - Phone:360-598-9712
Practice Address - Fax:360-598-9716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3999109Medicaid
WA3999109Medicaid