Basic Information
| Provider Information | |||||||||
| NPI: | 1538405709 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUND PAIN ALLIANCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MT BAKER PAIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4029 NORTHWEST AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982269077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607520518 | ||||||||
| FaxNumber: | 3606762896 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 E GEORGE HOPPER ROAD | ||||||||
| Address2: | SUITE #1 | ||||||||
| City: | BURLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982333154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607520518 | ||||||||
| FaxNumber: | 3606762896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2012 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STUIT | ||||||||
| AuthorizedOfficialFirstName: | ERIKA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3607520518 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QA1903X | MD00045352 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | EIN | 01 | WA | COMMERCIAL | OTHER |