Provider Demographics
NPI:1043368426
Name:SOUTHLAKE CLINIC INC PS
Entity type:Organization
Organization Name:SOUTHLAKE CLINIC INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-251-5110
Mailing Address - Street 1:PO BOX 59028
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-2028
Mailing Address - Country:US
Mailing Address - Phone:425-251-5110
Mailing Address - Fax:425-793-7458
Practice Address - Street 1:4011 TALBOT ROAD SOUTH
Practice Address - Street 2:SUITE 500
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055
Practice Address - Country:US
Practice Address - Phone:425-251-5110
Practice Address - Fax:425-793-4710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAFS.60293976261QA1903X, 261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA490003337OtherRAILROAD MEDICARE
WA0119463OtherL&I
WA7083660Medicaid
WA490003337OtherRAILROAD MEDICARE