Provider Demographics
NPI:1952057770
Name:HEART CLINIC OF TACOMA
Entity Type:Organization
Organization Name:HEART CLINIC OF TACOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:KOUKOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-279-3487
Mailing Address - Street 1:120 STATE AVE NE #122
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501
Mailing Address - Country:US
Mailing Address - Phone:253-279-3487
Mailing Address - Fax:
Practice Address - Street 1:120 STATE AVE NE #122
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501
Practice Address - Country:US
Practice Address - Phone:253-279-3487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty