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104TH AVENUE MEDICAL CLINIC INCORPORATED

Ambulatory Health Care Facilities Clinic/Center

Provider NPI: 1396921326

Organization Information:
Organization Name:  104TH AVENUE MEDICAL CLINIC INCORPORATED
Organization is not Subpart
Authorized Official:  RANU  CHOUDHARY  VICE-PRESIDENT  253-859-8371

Practice Location:
24604 104TH AVE SE # 202 KENT, WA 98030-5385 US
Tel: 253-859-8371  Fax: 253-859-9593

Business Mailing Address:
24604 104TH AVE SE # 202 KENT, WA 98030-5385 US
Tel: 253-859-8371  Fax: --

NPI Information:
NPI: 1396921326
Entity Type: Organization

Taxonomy:

PrimaryCodeCategory/DescriptionStateLicense Number
Y261Q00000XAmbulatory Health Care Facilities
Clinic/Center
WA37861

Other Provider Identifiers:

IssuerNumberStateType
1110378WA05



American Medical Association 2012 taxonomy code information

Code: 261Q00000X

Type:

Classification:



Definition:



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