Provider Demographics
NPI:1558897942
Name:STANLEY & UTTERBACK
Entity Type:Organization
Organization Name:STANLEY & UTTERBACK
Other - Org Name:OLYMPIA PODIATRY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROD
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-605-9249
Mailing Address - Street 1:9119 CLASSIC DR NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-9247
Mailing Address - Country:US
Mailing Address - Phone:216-469-5758
Mailing Address - Fax:
Practice Address - Street 1:3525 ENSIGN RD NE STE N
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5065
Practice Address - Country:US
Practice Address - Phone:360-943-9600
Practice Address - Fax:360-943-9694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO 60735213213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty