Provider Demographics
NPI:1285695007
Name:ANDERSON, DALE E (LCPO)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:E
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1994
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-1994
Mailing Address - Country:US
Mailing Address - Phone:360-956-3333
Mailing Address - Fax:360-956-3339
Practice Address - Street 1:2102 CARRIAGE DR SW
Practice Address - Street 2:SUITE 102
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5700
Practice Address - Country:US
Practice Address - Phone:360-956-3333
Practice Address - Fax:360-956-3339
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00000176222Z00000X
WAPS00000283224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3580WEOtherBLUESHIELD
WA9051483Medicaid
WA3580WEOtherBLUESHIELD
WA4256710001Medicare ID - Type Unspecified