Basic Information
| Provider Information | |||||||||
| NPI: | 1467907287 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE EVERETT CLINIC, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE EVERETT CLINIC AT EDMONDS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982065127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252583900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21401 72ND AVE W | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252583900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2016 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SLACK | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BOARD PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4253395445 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EVERETT PHYSICIANS, INC. P.S. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.