Provider Demographics
NPI:1801882915
Name:SOUTHWEST WASHINGTON DIAGNOSTICS LP
Entity type:Organization
Organization Name:SOUTHWEST WASHINGTON DIAGNOSTICS LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:THEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-736-0200
Mailing Address - Street 1:910 S SCHEUBER RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9027
Mailing Address - Country:US
Mailing Address - Phone:360-736-0200
Mailing Address - Fax:360-736-0380
Practice Address - Street 1:910 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9027
Practice Address - Country:US
Practice Address - Phone:360-736-0200
Practice Address - Fax:360-736-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7050479Medicaid
WA41265OtherL & I
WA41265OtherL & I