Provider Demographics
NPI:1891946257
Name:OLYMPIA NEUROLOGY, PLLC
Entity Type:Organization
Organization Name:OLYMPIA NEUROLOGY, PLLC
Other - Org Name:BRAIN & SPINE IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:W
Authorized Official - Last Name:KESTING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-464-6030
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-0960
Mailing Address - Country:US
Mailing Address - Phone:360-464-6030
Mailing Address - Fax:360-464-6000
Practice Address - Street 1:128 LILLY RD NE
Practice Address - Street 2:SUITE 101
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-7400
Practice Address - Country:US
Practice Address - Phone:360-464-6030
Practice Address - Fax:360-464-6000
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLYMPIA NEUROLOGY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-03
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602098189261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB21792Medicare PIN