Provider Demographics
NPI:1881638559
Name:TUMWATER FAMILY PRACTICE CLINIC
Entity Type:Organization
Organization Name:TUMWATER FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-754-6367
Mailing Address - Street 1:150 DENNIS ST SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-5459
Mailing Address - Country:US
Mailing Address - Phone:360-754-3637
Mailing Address - Fax:360-754-6429
Practice Address - Street 1:150 DENNIS ST SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-5459
Practice Address - Country:US
Practice Address - Phone:360-754-3637
Practice Address - Fax:360-754-6429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7022346Medicaid
WA77100OtherLABOR & INDUSTRIES
001050500Medicare PIN