Provider Demographics
NPI:1598205908
Name:THE EVERETT CLINIC, PLLC
Entity Type:Organization
Organization Name:THE EVERETT CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-339-5460
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-304-8431
Mailing Address - Fax:
Practice Address - Street 1:11800 NE 128TH ST STE 560
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7208
Practice Address - Country:US
Practice Address - Phone:425-899-5200
Practice Address - Fax:425-899-5204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVITA EVERETT PHYSICIANS, INC. P.S.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-03
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 332B00000X
WA50D0704127291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical Laboratory