Provider Demographics
NPI:1386694099
Name:OLYMPIC PENINSULA KIDNEY CENTER
Entity type:Organization
Organization Name:OLYMPIC PENINSULA KIDNEY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:ARDEL
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CNN
Authorized Official - Phone:206-915-9502
Mailing Address - Street 1:450 S KITSAP BLVD
Mailing Address - Street 2:SUITE 178
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3773
Mailing Address - Country:US
Mailing Address - Phone:360-895-7795
Mailing Address - Fax:360-895-7835
Practice Address - Street 1:450 S KITSAP BLVD
Practice Address - Street 2:SUITE 178
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3773
Practice Address - Country:US
Practice Address - Phone:360-895-7795
Practice Address - Fax:360-895-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3999109Medicaid
WA3999109Medicaid