Provider Demographics
NPI:1316161136
Name:FISHERS LANDING URGENT AND FAMILY CARE
Entity type:Organization
Organization Name:FISHERS LANDING URGENT AND FAMILY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-882-6997
Mailing Address - Street 1:PO BOX 873236
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98687-3236
Mailing Address - Country:US
Mailing Address - Phone:360-335-1107
Mailing Address - Fax:360-335-1109
Practice Address - Street 1:3307 EVERGREEN WAY STE 704
Practice Address - Street 2:
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-2065
Practice Address - Country:US
Practice Address - Phone:360-335-1107
Practice Address - Fax:360-335-1109
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FISHERS LANDING URGENT AND FAMILY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-12
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA17866261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8854964Medicare PIN