Provider Demographics
NPI:1447451216
Name:CANYON CREEK CLINIC, PLLC
Entity type:Organization
Organization Name:CANYON CREEK CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:KNOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-424-2201
Mailing Address - Street 1:19125 N CREEK PKWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-8035
Mailing Address - Country:US
Mailing Address - Phone:425-424-2201
Mailing Address - Fax:425-398-4172
Practice Address - Street 1:19125 N CREEK PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-8035
Practice Address - Country:US
Practice Address - Phone:425-424-2201
Practice Address - Fax:425-398-4172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care