Provider Demographics
NPI:1396056859
Name:KAHLSTROM, ERIC EDWARD (LMP)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:EDWARD
Last Name:KAHLSTROM
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 14TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-3412
Mailing Address - Country:US
Mailing Address - Phone:206-963-8644
Mailing Address - Fax:206-329-0310
Practice Address - Street 1:1530 14TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-3412
Practice Address - Country:US
Practice Address - Phone:206-963-8644
Practice Address - Fax:206-329-0310
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006967174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist