Basic Information
Provider Information | |||||||||
NPI: | 1811932189 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY CARE NETWORK PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LYNDEN FAMILY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 709 W ORCHARD DRIVE | ||||||||
Address2: | SUITE 4 | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982250066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603189705 | ||||||||
FaxNumber: | 3603181085 | ||||||||
Practice Location | |||||||||
Address1: | 1610 GROVER ST | ||||||||
Address2: | SUITE D1 | ||||||||
City: | LYNDEN | ||||||||
State: | WA | ||||||||
PostalCode: | 982641539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603541333 | ||||||||
FaxNumber: | 3603545399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2006 | ||||||||
LastUpdateDate: | 06/26/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HIPSKIND | ||||||||
AuthorizedOfficialFirstName: | MARCY | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | FAMILY CARE NETWORK PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3603189705 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FAMILY CARE NETWORK PLLC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 192942506 | 01 | WA | US DEPT OF LABOR CLINIC # | OTHER |