Provider Demographics
NPI:1902121395
Name:OLYMPIC PENINSULA KIDNEY CENTER
Entity Type:Organization
Organization Name:OLYMPIC PENINSULA KIDNEY CENTER
Other - Org Name:OLYMPIC PENINSULA KIDNEY CENTER NORTHWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:ARDEL
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CNN
Authorized Official - Phone:206-915-9502
Mailing Address - Street 1:2500 W SIMS WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-2234
Mailing Address - Country:US
Mailing Address - Phone:360-479-5908
Mailing Address - Fax:360-479-5787
Practice Address - Street 1:2500 W SIMS WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2234
Practice Address - Country:US
Practice Address - Phone:360-479-5908
Practice Address - Fax:360-479-5787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA502565Medicare Oscar/Certification