Provider Demographics
NPI:1578001186
Name:SOUTH SOUND PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:SOUTH SOUND PEDIATRICS, PLLC
Other - Org Name:SOUTH SOUND PEDIATRICS HEALTH HOMES
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CNDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STRANDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-918-0604
Mailing Address - Street 1:3516 12TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5218
Mailing Address - Country:US
Mailing Address - Phone:360-456-1600
Mailing Address - Fax:360-456-6504
Practice Address - Street 1:3516 12TH AVE NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-456-1600
Practice Address - Fax:360-456-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602083232208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1029486Medicaid