Basic Information
| Provider Information | |||||||||
| NPI: | 1053431684 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUND PAIN ALLIANCE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PUGET SOUND PAIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 39324 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984963324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539839390 | ||||||||
| FaxNumber: | 2539830066 | ||||||||
| Practice Location | |||||||||
| Address1: | 11306 BRIDGEPORT WAY SW | ||||||||
| Address2: | #D | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539839390 | ||||||||
| FaxNumber: | 2539830066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | STUIT | ||||||||
| AuthorizedOfficialFirstName: | ERIKA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3607520518 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PUGET SOUND PAIN CLINIC, P.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | OP00001595 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QP3300X | OP00001595 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | 7121882 | 05 | WA | MEDICAID |