Basic Information
Provider Information | |||||||||
NPI: | 1598255903 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPORTS AND SPINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPORTS AND SPINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 827 | ||||||||
Address2: |   | ||||||||
City: | BELLEVUE | ||||||||
State: | WA | ||||||||
PostalCode: | 980090827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4257741538 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3900 FACTORIA BLVD SE STE A | ||||||||
Address2: |   | ||||||||
City: | BELLEVUE | ||||||||
State: | WA | ||||||||
PostalCode: | 980061234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4257741538 | ||||||||
FaxNumber: | 4257441527 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2018 | ||||||||
LastUpdateDate: | 05/11/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HONG | ||||||||
AuthorizedOfficialFirstName: | HYUN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
AuthorizedOfficialTelephone: | 4257741538 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WASHINGTON CENTER FOR PAIN MANAGEMENT, PLLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.