Provider Demographics
NPI:1649415720
Name:PACIFIC LUTHERAN UNIVERISTY STUDENT HEALTH CENTER
Entity Type:Organization
Organization Name:PACIFIC LUTHERAN UNIVERISTY STUDENT HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:WINNIFRED
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:253-862-7050
Mailing Address - Street 1:4018 CALDWELL RD E
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98372-9234
Mailing Address - Country:US
Mailing Address - Phone:253-862-1050
Mailing Address - Fax:
Practice Address - Street 1:PACIFIC LUTHERAN UNIVERSITY STUDENT HEALTH CTR
Practice Address - Street 2:12012 PARK AVE SOUTH
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98447-0001
Practice Address - Country:US
Practice Address - Phone:253-535-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA910565571302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA910565571OtherTAX ID NUMBER