Provider Demographics
NPI:1669645172
Name:CHILDREN'S CLINIC OF SOUTH SNOHOMISH COUNTY, LTD
Entity Type:Organization
Organization Name:CHILDREN'S CLINIC OF SOUTH SNOHOMISH COUNTY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOVAERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-775-7464
Mailing Address - Street 1:21600 HWY 99
Mailing Address - Street 2:SUITE 290
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8012
Mailing Address - Country:US
Mailing Address - Phone:425-778-0191
Mailing Address - Fax:425-672-2110
Practice Address - Street 1:21600 HWY 99
Practice Address - Street 2:SUITE 290
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8012
Practice Address - Country:US
Practice Address - Phone:425-778-0191
Practice Address - Fax:425-672-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7077027Medicaid