Provider Demographics
NPI:1336584119
Name:WATER'S EDGE FAMILY PRACTICE & WELLNESS CENTER
Entity Type:Organization
Organization Name:WATER'S EDGE FAMILY PRACTICE & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNASTASIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVSCEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-221-1060
Mailing Address - Street 1:PO BOX 1327
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98260-1327
Mailing Address - Country:US
Mailing Address - Phone:360-221-1060
Mailing Address - Fax:360-221-1062
Practice Address - Street 1:221 SECOND STREET
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:WA
Practice Address - Zip Code:98260
Practice Address - Country:US
Practice Address - Phone:360-221-1060
Practice Address - Fax:360-221-1062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60091880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty