104TH AVENUE MEDICAL CLINIC INCORPORATED
NPI 1396921326
Clinic/Center in Kent, WA
About 104th Avenue Medical Clinic Incorporated NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
104TH AVENUE MEDICAL CLINIC INCORPORATED (NPI 1396921326) is a healthcare organization registered as a clinic/center in Kent, Washington and active in the NPI registry since January 2008. The organization holds a CLIA Waiver certificate valid through April 4, 2028 and lists Ranu Choudhary, Vice-president, as its authorized official.
NPPES Registry Identity
Specialties & Licenses
Other Identifiers 3
Medicare Participation & PECOS CMS
Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.
Medicare Enrollment Status
Enrolled in Medicare (PECOS)
104th Avenue Medical Clinic Incorporated is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
Clinicians Billing Medicare Through This Organization
Medicare enrollment records show 1 clinician reassigns Medicare billing to 104th Avenue Medical Clinic Incorporated, which bills Medicare for the services this clinician delivers.
Clinician (1)
Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
CLIA Laboratory Certificates CMS CLIA
Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.
Certificate of Waiver 50D0976109
104th Avenue Medical Clinic Inc · Kent, WAFrequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is 104th Avenue Medical Clinic Incorporated's NPI number?
The NPI number for 104th Avenue Medical Clinic Incorporated is 1396921326. It was assigned to this organization in the NPPES registry on January 22, 2008.
Where is 104th Avenue Medical Clinic Incorporated located?
104th Avenue Medical Clinic Incorporated is located at 24604 104th Ave SE # 202, Kent, WA 98030. The listed phone number is (253) 859-8371.
What is 104th Avenue Medical Clinic Incorporated's specialty?
The primary specialty registered for this NPI is Clinic/Center with taxonomy code 261Q00000X.
Is 104th Avenue Medical Clinic Incorporated enrolled in Medicare?
Yes. 104th Avenue Medical Clinic Incorporated is registered in the Medicare PECOS enrollment system.
How many clinicians bill Medicare through 104th Avenue Medical Clinic Incorporated?
According to the CMS Revalidation Reassignment List (October 2026 release), 1 clinician (Internal Medicine) reassigns their Medicare billing to 104th Avenue Medical Clinic Incorporated. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Does 104th Avenue Medical Clinic Incorporated hold a CLIA laboratory certificate?
Yes. A Certificate of Waiver (number 50D0976109) is associated with this NPI, valid through April 4, 2028. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.
When was this NPI record last updated?
The NPPES record for 104th Avenue Medical Clinic Incorporated was last updated on October 1, 2014. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 12 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# 104th Avenue Medical Clinic Incorporated · NPI 1396921326
Clinic/Center organization in Kent, Washington. Organization record, active in the CMS NPPES registry since January 22, 2008.
## Identity
- **NPI:** 1396921326 (Entity type: Organization)
- **Enumerated:** January 22, 2008
- **Primary specialty:** Clinic/Center · taxonomy 261Q00000X
- **Organization subpart:** No
- **Authorized official:** Ranu Choudhary, VICE-PRESIDENT
## Practice location
- **Address:** 24604 104TH AVE SE, # 202, Kent, WA 98030-5385
- **Phone:** (253) 859-8371 · **Fax:** (253) 859-9593
## Medicare
- **Medicare:** Enrolled in Medicare (PECOS)
- **Clinicians billing through this organization:** 1 clinician (Internal Medicine) reassigns Medicare billing to this organization (form CMS-855R) · CMS Revalidation Reassignment List, October 2026 release
## Record status
- **NPPES last updated:** October 1, 2014
- **Other identifiers:** Medicare UPIN H20548; Medicaid 1110378 (WA); Medicare PIN G8871735
- **CLIA laboratory certificates:** 1 on file
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Source: [NPI Profile](https://npiprofile.com/npi/1396921326) · Data from the CMS NPPES public registry.