Provider Demographics
NPI:1710305420
Name:KELIOTTMD OF SEATTLE LLC
Entity Type:Organization
Organization Name:KELIOTTMD OF SEATTLE LLC
Other - Org Name:BODYLOGICMD OF SEATTLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-351-7516
Mailing Address - Street 1:2817 E PARK DR E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-2003
Mailing Address - Country:US
Mailing Address - Phone:206-351-7516
Mailing Address - Fax:
Practice Address - Street 1:811 1ST AVE STE 626
Practice Address - Street 2:SUITE 626
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1434
Practice Address - Country:US
Practice Address - Phone:206-351-7516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60308596261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center