NPI 1982879045

Lake Wilderness Medical Clinic LLC

Organisation Exclusive Provider Organization Maple Valley, WA

Practice location

Address: 26907 Maple Valley Black Diamond Rd SE, Maple Valley, WA 98038-8314
Phone: (425) 432-9611
Fax: (206) 973-5399
Mailing address: PO Box 1142, Ravensdale, WA 98051-1142

Authorised official

Name: Chester E Jangala
Title: Physician
Phone: (425) 432-9611

Registered specialties

Exclusive Provider Organization Primary

Managed Care Organizations Taxonomy 302F00000X Licence MD00023662 (WA)

Other Exclusive Provider Organization providers in Washington →

Registry record

NPI: 1982879045
Entity type: Organization
NPI issued: 29 Apr 2008
Record last updated: 29 Apr 2008

Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.