Provider Demographics
NPI:1992110084
Name:MAXIM
Entity type:Organization
Organization Name:MAXIM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDIVIDUAL PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MADISON
Authorized Official - Middle Name:
Authorized Official - Last Name:UMPHRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-429-5502
Mailing Address - Street 1:4301 S PINE ST
Mailing Address - Street 2:SUITE 505
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4301 S PINE ST
Practice Address - Street 2:SUITE 505
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7264
Practice Address - Country:US
Practice Address - Phone:253-292-4354
Practice Address - Fax:855-373-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health