Basic Information
| Provider Information | |||||||||
| NPI: | 1790966851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DPMSALTONPRWA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50150 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980150150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252285228 | ||||||||
| FaxNumber: | 4252285733 | ||||||||
| Practice Location | |||||||||
| Address1: | 11201 88TH AVE E | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983733802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538413668 | ||||||||
| FaxNumber: | 2538410878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | SALTON | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | LYN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2538413668 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO00000834 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7141864 | 05 | WA | MEDICAID |