Lake Wilderness Medical Clinic LLC

Primary specialty

Exclusive Provider OrganizationTaxonomy code 302F00000X

License

MD00023662 Issued in WA

Legal business name

LAKE WILDERNESS MEDICAL CLINIC LLC

Practice address

26907 Maple Valley Black Diamond Rd SE
Maple Valley, WA 98038-8314

Phone

(425) 432-9611

Fax

(206) 973-5399

NPI assigned

Apr 29, 2008

Organization subpart

No

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

Authorized official

Name

Chester E Jangala Jr., MD

Title

Physician

Phone

(425) 432-9611

Specialties & licenses 1

Addresses

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

{
    "created_epoch": "1209427200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1209427200000",
    "number": "1982879045",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1142",
            "city": "RAVENSDALE",
            "state": "WA",
            "postal_code": "980511142",
            "telephone_number": "425-432-9611",
            "fax_number": "206-973-5399"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "26907 MAPLE VALLEY BLACK DIAMOND RD SE",
            "city": "MAPLE VALLEY",
            "state": "WA",
            "postal_code": "980388314",
            "telephone_number": "425-432-9611",
            "fax_number": "206-973-5399"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE WILDERNESS MEDICAL CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-29",
        "last_updated": "2008-04-29",
        "status": "A",
        "authorized_official_last_name": "JANGALA",
        "authorized_official_first_name": "CHESTER",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "425-432-9611",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "302F00000X",
            "taxonomy_group": "",
            "desc": "Exclusive Provider Organization",
            "state": "WA",
            "license": "MD00023662",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Elvina Kuzmich, MS
• L Carlos Morales DDS PS
• Tanya Marie Labrador
• Victoria Labrie, ATC
• Lake Wilderness Medical Clinic LLC (Chet Jangala, MD)
• Bronston Stuart Lallier, PHARMD
• Jessica Lancaster, DO
• Alyssa N Laney
• Sandy Larios
• Klayton Quinn Larsson

• Exclusive Provider Organization in Maple Valley, WA
• Providers in Maple Valley, WA by specialty
• Exclusive Provider Organization in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2008; 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.