Basic Information
| Provider Information | |||||||||
| NPI: | 1467582320 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTSIDE HAND REHABILITATION CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12911-120TH AVE NE | ||||||||
| Address2: | SUITE F-120 | ||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980343025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258231389 | ||||||||
| FaxNumber: | 4258203996 | ||||||||
| Practice Location | |||||||||
| Address1: | 12911-120TH AVE NE | ||||||||
| Address2: | SUITE F-120 | ||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980343025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258231389 | ||||||||
| FaxNumber: | 4258203996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 12/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | FULLENWIDER | ||||||||
| AuthorizedOfficialFirstName: | LYNNLEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4258231389 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | OTRL CHT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | EA2218 | 01 | WA | REGENCE | OTHER | 7680697 | 05 | WA | MEDICAID | T06695 | 01 | WA | PREMERA | OTHER | 34460 | 01 | WA | L & I | OTHER |