Provider Demographics
NPI:1760808836
Name:OVERLAKE REPRODUCTIVE HEALTH INC PS.
Entity Type:Organization
Organization Name:OVERLAKE REPRODUCTIVE HEALTH INC PS.
Other - Org Name:OVERLAKE REPRODUCTIVE HEALTH INC.- AMBULATORY SURGICAL FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-646-4700
Mailing Address - Street 1:11232 NE 15TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3739
Mailing Address - Country:US
Mailing Address - Phone:425-646-4700
Mailing Address - Fax:253-646-1076
Practice Address - Street 1:11232 NE 15TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3739
Practice Address - Country:US
Practice Address - Phone:425-646-4700
Practice Address - Fax:253-646-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAASF.FS.60350164261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAASF.FS.60350164OtherCERTIFICATION/LICENSE NUMBER