Basic Information
| Provider Information | |||||||||
| NPI: | 1760808836 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OVERLAKE REPRODUCTIVE HEALTH INC PS. | ||||||||
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| OtherOrganizationName: | OVERLAKE REPRODUCTIVE HEALTH INC.- AMBULATORY SURGICAL FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11232 NE 15TH ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256464700 | ||||||||
| FaxNumber: | 2536461076 | ||||||||
| Practice Location | |||||||||
| Address1: | 11232 NE 15TH ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256464700 | ||||||||
| FaxNumber: | 2536461076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 03/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4256464700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | ASF.FS.60350164 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | ASF.FS.60350164 | 01 | WA | CERTIFICATION/LICENSE NUMBER | OTHER |