Provider Demographics
NPI:1558446211
Name:SOUTH SOUND FAMILY & SPORTS
Entity Type:Organization
Organization Name:SOUTH SOUND FAMILY & SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-709-9500
Mailing Address - Street 1:2960 LIMITED LN NW STE A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4541
Mailing Address - Country:US
Mailing Address - Phone:360-709-9500
Mailing Address - Fax:360-754-4517
Practice Address - Street 1:2960-A LIMITED LANE NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4541
Practice Address - Country:US
Practice Address - Phone:360-709-9500
Practice Address - Fax:360-754-4517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602369889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7122450OtherDSHS
50D1031645OtherCLIA
O186019OtherL & I
WAG8807367Medicare PIN