Provider Demographics
NPI:1841407285
Name:PUYALLUP CHILDREN'S CLINIC, PLLC
Entity Type:Organization
Organization Name:PUYALLUP CHILDREN'S CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-848-1572
Mailing Address - Street 1:1322 3RD ST SE
Mailing Address - Street 2:STE #240
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3771
Mailing Address - Country:US
Mailing Address - Phone:253-848-1572
Mailing Address - Fax:253-841-3719
Practice Address - Street 1:1322 3RD ST SE
Practice Address - Street 2:STE #240
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3771
Practice Address - Country:US
Practice Address - Phone:253-848-1572
Practice Address - Fax:253-841-3719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty