Provider Demographics
NPI:1619913753
Name:WESTERN WASHINGTON MEDICAL GROUP DEPARTMENT OF DEXA SCAN
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP DEPARTMENT OF DEXA SCAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:VELDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-4041
Mailing Address - Street 1:1728 W MARINE VIEW DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2094
Mailing Address - Country:US
Mailing Address - Phone:425-259-4041
Mailing Address - Fax:
Practice Address - Street 1:3216 NORTON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4290
Practice Address - Country:US
Practice Address - Phone:425-303-9810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA=========OtherTIN