Provider Demographics
NPI:1548319171
Name:SOUTHLAKE CLINIC INC PS
Entity type:Organization
Organization Name:SOUTHLAKE CLINIC INC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-251-5110
Mailing Address - Street 1:PO BOX 59028
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-2028
Mailing Address - Country:US
Mailing Address - Phone:425-251-5110
Mailing Address - Fax:425-793-4707
Practice Address - Street 1:3915 TALBOT ROAD SOUTH
Practice Address - Street 2:SUITE 300
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055
Practice Address - Country:US
Practice Address - Phone:425-251-5110
Practice Address - Fax:425-226-9085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHLAKE CLINIC INC PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-10
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600052154291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory