Provider Demographics
NPI:1255603874
Name:ORCHARD MEDICAL CLINIC
Entity type:Organization
Organization Name:ORCHARD MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PACIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-474-7100
Mailing Address - Street 1:7501 92ND AVENUE CT SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-3973
Mailing Address - Country:US
Mailing Address - Phone:253-588-0058
Mailing Address - Fax:253-589-4862
Practice Address - Street 1:5320 ORCHARD ST W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98467-3633
Practice Address - Country:US
Practice Address - Phone:253-474-7100
Practice Address - Fax:253-474-2677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORCHARD MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-27
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000380965261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA11155922Medicaid
WA711938001OtherGROUP HEALTH
GAP00850060OtherRAILROAD MEDICAARE