Provider Demographics
NPI:1992486906
Name:WASHINGTON PAIN AND SPINE SPECIALISTS LLC
Entity type:Organization
Organization Name:WASHINGTON PAIN AND SPINE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:MAMBALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-463-4101
Mailing Address - Street 1:4957 LAKEMONT BLVD SE STE C-425
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-7801
Mailing Address - Country:US
Mailing Address - Phone:240-463-4101
Mailing Address - Fax:
Practice Address - Street 1:3525 ENSIGN RD NE STE J
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5065
Practice Address - Country:US
Practice Address - Phone:240-463-4101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain