Provider Demographics
NPI:1639776842
Name:PACIFIC VASCULAR INCORPORATED
Entity Type:Organization
Organization Name:PACIFIC VASCULAR INCORPORATED
Other - Org Name:PACIFIC VASCULAR-PT ANGELES
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/TECHNICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RVT
Authorized Official - Phone:425-398-7781
Mailing Address - Street 1:11714 N CREEK PKWY N STE 100
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-8099
Mailing Address - Country:US
Mailing Address - Phone:425-486-8868
Mailing Address - Fax:425-486-8976
Practice Address - Street 1:315 E 8TH ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6217
Practice Address - Country:US
Practice Address - Phone:360-504-3842
Practice Address - Fax:360-504-3843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-01
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7015852Medicaid