Basic Information
| Provider Information | |||||||||
| NPI: | 1588067896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WASHINGTON CENTER FOR PAIN MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827 | ||||||||
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| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980090827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257741538 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1408 3RD ST SE | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983723702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257741538 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2014 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JAE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4257741538 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6229050008 | 01 | WA | DME PTAN | OTHER |