Provider Demographics
NPI:1548791924
Name:SOUTHLAKE SELECT, PC
Entity Type:Organization
Organization Name:SOUTHLAKE SELECT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINICK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:TOULOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-793-4702
Mailing Address - Street 1:4011 TALBOT RD S
Mailing Address - Street 2:440
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5773
Mailing Address - Country:US
Mailing Address - Phone:425-793-4702
Mailing Address - Fax:425-271-5382
Practice Address - Street 1:4011 TALBOT RD S
Practice Address - Street 2:440
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5773
Practice Address - Country:US
Practice Address - Phone:425-793-4702
Practice Address - Fax:425-271-5382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
WA0020685305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA05805Medicare UPIN