Basic Information
| Provider Information | |||||||||
| NPI: | 1053364950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YELM FAMILY MEDICINE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 TAHOMA BLVD SE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | YELM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604587761 | ||||||||
| FaxNumber: | 3604586612 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 TAHOMA BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | YELM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985977735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604587761 | ||||||||
| FaxNumber: | 3604586612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 10/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | LONGMIRE | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3604587761 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 62140 | 01 | WA | L&I | OTHER | 7068828 | 05 | WA | MEDICAID |