Provider Demographics
NPI:1174570766
Name:OLYMPIA NEUROLOGY, PLLC
Entity type:Organization
Organization Name:OLYMPIA NEUROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ENGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-413-8551
Mailing Address - Street 1:525 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5101
Mailing Address - Country:US
Mailing Address - Phone:360-413-8551
Mailing Address - Fax:360-413-8827
Practice Address - Street 1:525 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:360-413-8551
Practice Address - Fax:360-413-8827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7107337Medicaid
WA7107337Medicaid