Basic Information
Provider Information | |||||||||
NPI: | 1306218284 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUND PAIN ALLIANCE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PUGET SOUND PAIN CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 39324 | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 984963324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539839390 | ||||||||
FaxNumber: | 2539830066 | ||||||||
Practice Location | |||||||||
Address1: | 17615 SE 272ND ST STE 109 | ||||||||
Address2: |   | ||||||||
City: | COVINGTON | ||||||||
State: | WA | ||||||||
PostalCode: | 980424957 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539839390 | ||||||||
FaxNumber: | 2539830066 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/30/2015 | ||||||||
LastUpdateDate: | 07/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STUIT | ||||||||
AuthorizedOfficialFirstName: | ERIKA | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3607520518 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN | ||||||||
NPICertificationDate: |   |
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 |   | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 261QP3300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
ID | Type | State | Issuer | Description | OP00001595 | 01 | WA | STATE LICENSE | OTHER |