Provider Demographics
NPI:1053417675
Name:PRUDENCIO G TIBLE MD PC
Entity type:Organization
Organization Name:PRUDENCIO G TIBLE MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PRUDENCIO
Authorized Official - Middle Name:GALVEZ
Authorized Official - Last Name:TIBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-725-8043
Mailing Address - Street 1:PO BOX 18936
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118
Mailing Address - Country:US
Mailing Address - Phone:206-725-8043
Mailing Address - Fax:206-760-1359
Practice Address - Street 1:5023 S BARTON PLACE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118
Practice Address - Country:US
Practice Address - Phone:206-725-8043
Practice Address - Fax:206-760-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center