Basic Information
| Provider Information | |||||||||
| NPI: | 1558446211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH SOUND FAMILY & SPORTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 LIMITED LN NW STE A | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607099500 | ||||||||
| FaxNumber: | 3607544517 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960-A LIMITED LANE NW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607099500 | ||||||||
| FaxNumber: | 3607544517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | BLAKE | ||||||||
| AuthorizedOfficialFirstName: | JENNY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OPS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3607099500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 602369889 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7122450 | 01 | DSHS | OTHER | 50D1031645 | 01 | CLIA | OTHER | O186019 | 01 | L & I | OTHER |