Provider Demographics
NPI:1821237488
Name:SOUTHLAKE CLINIC DME
Entity Type:Organization
Organization Name:SOUTHLAKE CLINIC DME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-251-5110
Mailing Address - Street 1:PO BOX 59028
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-2028
Mailing Address - Country:US
Mailing Address - Phone:425-251-5110
Mailing Address - Fax:425-793-7458
Practice Address - Street 1:4033 TALBOT RD S
Practice Address - Street 2:SUITE 500
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5772
Practice Address - Country:US
Practice Address - Phone:425-251-5110
Practice Address - Fax:425-793-7382
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHLAKE CLINIC, INC., P.S.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-05
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600 052 154332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9062571Medicaid