Provider Demographics
NPI:1295142065
Name:OLYMPIC PENINSULA KIDNEY CENTER
Entity type:Organization
Organization Name:OLYMPIC PENINSULA KIDNEY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CNN
Authorized Official - Phone:206-915-9502
Mailing Address - Street 1:2740 CLARE AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3330
Mailing Address - Country:US
Mailing Address - Phone:360-479-5908
Mailing Address - Fax:360-479-5787
Practice Address - Street 1:2740 CLARE AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3330
Practice Address - Country:US
Practice Address - Phone:360-479-5908
Practice Address - Fax:360-479-5787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLYMPIC PENINSULA KIDNEY CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-14
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA502580Medicare Oscar/Certification