Provider Demographics
NPI:1710219522
Name:WARREN PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:WARREN PHYSICIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:M
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:360-704-9116
Mailing Address - Street 1:1401 MARVIN RD NE
Mailing Address - Street 2:STE 307 PMB 266
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5749
Mailing Address - Country:US
Mailing Address - Phone:360-491-5055
Mailing Address - Fax:
Practice Address - Street 1:5420 22ND AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2804
Practice Address - Country:US
Practice Address - Phone:360-491-5055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty