Provider Demographics
NPI:1053364950
Name:YELM FAMILY MEDICINE, PLLC
Entity type:Organization
Organization Name:YELM FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LONGMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-458-7761
Mailing Address - Street 1:201 TAHOMA BLVD SE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597
Mailing Address - Country:US
Mailing Address - Phone:360-458-7761
Mailing Address - Fax:360-458-6612
Practice Address - Street 1:201 TAHOMA BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-7735
Practice Address - Country:US
Practice Address - Phone:360-458-7761
Practice Address - Fax:360-458-6612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA62140OtherL&I
WA7068828Medicaid
WAAB07107Medicare ID - Type Unspecified