Provider Demographics
NPI:1821097429
Name:PUYALLUP RADIOLOGICAL ASSOCS, INC.
Entity Type:Organization
Organization Name:PUYALLUP RADIOLOGICAL ASSOCS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:COTY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCREYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-845-9511
Mailing Address - Street 1:800 S MERIDIAN
Mailing Address - Street 2:SUITE B
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-6995
Mailing Address - Country:US
Mailing Address - Phone:253-845-9511
Mailing Address - Fax:253-840-3513
Practice Address - Street 1:800 S MERIDIAN
Practice Address - Street 2:SUITE B
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-6995
Practice Address - Country:US
Practice Address - Phone:253-845-9511
Practice Address - Fax:253-840-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0040900OtherDEPT LABOR & INDUSTRIES
WA7860307Medicaid
WA7860307Medicaid