Provider Demographics
NPI:1598982324
Name:THE CLINIC AT PANORAMA CITY,PS
Entity Type:Organization
Organization Name:THE CLINIC AT PANORAMA CITY,PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAIRBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-491-4460
Mailing Address - Street 1:4044 15TH LN SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503
Mailing Address - Country:US
Mailing Address - Phone:360-491-4460
Mailing Address - Fax:360-491-3090
Practice Address - Street 1:4044 15TH LN SE
Practice Address - Street 2:SUITE A
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503
Practice Address - Country:US
Practice Address - Phone:360-491-4460
Practice Address - Fax:360-491-3090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB20379Medicare ID - Type UnspecifiedGROUP NUMBER