Provider Demographics
NPI:1902083983
Name:CLEAR CHOICE SKIN SOLUTIONS OF OLYMPIA
Entity Type:Organization
Organization Name:CLEAR CHOICE SKIN SOLUTIONS OF OLYMPIA
Other - Org Name:CLEAR CHOICE SKIN SOLUTIONS & LASER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LMP, LE, MEDICAL BILLER, OFFICE MAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KRUGER
Authorized Official - Suffix:
Authorized Official - Credentials:LMP, LE
Authorized Official - Phone:360-943-7546
Mailing Address - Street 1:1800 COOPER POINT RD SW STE 2A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1037
Mailing Address - Country:US
Mailing Address - Phone:360-943-7546
Mailing Address - Fax:360-943-7568
Practice Address - Street 1:1800 COOPER POINT RD SW STE 2A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1037
Practice Address - Country:US
Practice Address - Phone:360-943-7546
Practice Address - Fax:360-943-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026210305R00000X
WAMA00023689305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization