Provider Demographics
NPI:1104149210
Name:EAR, NOSE, THROAT & ALLERGY ASSOICATIES PS
Entity type:Organization
Organization Name:EAR, NOSE, THROAT & ALLERGY ASSOICATIES PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-770-8454
Mailing Address - Street 1:104 27TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-1145
Mailing Address - Country:US
Mailing Address - Phone:253-770-8454
Mailing Address - Fax:253-770-8992
Practice Address - Street 1:104 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-1145
Practice Address - Country:US
Practice Address - Phone:253-770-8454
Practice Address - Fax:253-770-8992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD60130143231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty