Southlake Clinic Inc PS

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

License

FS.60293976 Issued in WA

Legal business name

SOUTHLAKE CLINIC INC PS

Practice address

4011 Talbot Road South
Suite 500
Renton, WA 98055

Phone

(425) 251-5110

Fax

(425) 793-4710

NPI assigned

Jan 8, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Marianne Larson

Title

Director of Operations

Phone

(425) 251-5110

Specialties & licenses 2

Addresses

Other identifiers 3

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168214400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1353369600000",
    "number": "1043368426",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 59028",
            "city": "RENTON",
            "state": "WA",
            "postal_code": "980582028",
            "telephone_number": "425-251-5110",
            "fax_number": "425-793-7458"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4011 TALBOT ROAD SOUTH",
            "address_2": "SUITE 500",
            "city": "RENTON",
            "state": "WA",
            "postal_code": "98055",
            "telephone_number": "425-251-5110",
            "fax_number": "425-793-4710"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHLAKE CLINIC INC PS",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-08",
        "last_updated": "2012-11-20",
        "status": "A",
        "authorized_official_last_name": "LARSON",
        "authorized_official_first_name": "MARIANNE",
        "authorized_official_title_or_position": "DIRECTOR OF OPERATIONS",
        "authorized_official_telephone_number": "425-251-5110"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "WA",
            "license": "FS.60293976",
            "primary": true
        },
        {
            "code": "261QE0800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Endoscopy",
            "state": "WA",
            "license": "FS.60293976",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "490003337",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "L&I",
            "identifier": "0119463",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7083660",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Michele K Souligny, RN, MSN-ED
• Sound Association Western Washington LLC
• South Sound Inpatient Physicians PLLC
• South Sound Oncology Services, P.C.
• Southlake Clinic DME
• Southlake Clinic Inc PS
• Southlake Clinic Inc PS
• Southlake Clinic Inc PS
• Southlake Clinic Inc., P.S.
• Southlake Psychiatric Center

• Ambulatory Surgical Clinic/Center in Renton, WA
• Providers in Renton, WA by specialty
• Ambulatory Surgical Clinic/Center in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 20, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.