Provider Demographics
NPI:1396921326
Name:104TH AVENUE MEDICAL CLINIC INCORPORATED
Entity type:Organization
Organization Name:104TH AVENUE MEDICAL CLINIC INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANU
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOUDHARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-859-8371
Mailing Address - Street 1:24604 104TH AVE SE
Mailing Address - Street 2:# 202
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-5385
Mailing Address - Country:US
Mailing Address - Phone:253-859-8371
Mailing Address - Fax:
Practice Address - Street 1:24604 104TH AVE SE
Practice Address - Street 2:# 202
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-5385
Practice Address - Country:US
Practice Address - Phone:253-859-8371
Practice Address - Fax:253-859-9593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA37861261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1110378Medicaid
H20548Medicare UPIN
G8871735Medicare PIN