Provider Demographics
NPI:1659758290
Name:FOOT AND ANKLE CENTER OF ISSAQUAH LLC
Entity Type:Organization
Organization Name:FOOT AND ANKLE CENTER OF ISSAQUAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-947-2880
Mailing Address - Street 1:6947 COAL CREEK PKWY SE
Mailing Address - Street 2:#753
Mailing Address - City:NEWCASTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98059-3136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22510 SE 64TH PL
Practice Address - Street 2:UNIT 120
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5390
Practice Address - Country:US
Practice Address - Phone:425-947-2880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60204241213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty