Provider Demographics
NPI:1629113956
Name:FAMILY MEDICINE CLINIC OF FEDERAL WAY
Entity Type:Organization
Organization Name:FAMILY MEDICINE CLINIC OF FEDERAL WAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VUTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-838-4140
Mailing Address - Street 1:PO BOX 6015
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98063-6015
Mailing Address - Country:US
Mailing Address - Phone:866-499-8990
Mailing Address - Fax:253-838-4145
Practice Address - Street 1:34618 11TH PL S. SUITE #100
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003
Practice Address - Country:US
Practice Address - Phone:866-499-8990
Practice Address - Fax:253-838-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044823174400000X
WA00044823207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1122118Medicaid
WA1122118Medicaid
WAI41011Medicare UPIN