1174799282 NPI number — SOUTH SOUND NEUROSURGERY PLLC

Table of content: (NPI 1174799282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174799282 NPI number — SOUTH SOUND NEUROSURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SOUND NEUROSURGERY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PRECISION IMAGING
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174799282
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1519 3RD ST SE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98372-3742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-841-8939
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1519 3RD ST SE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-3742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-841-8939
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BALDOCK
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
BOYD
Authorized Official Title or Position:
OFFICER AND AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-234-5900

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0164168 . This is a "WASHINGTON STATE DEPT. OF LABOR AND INDUSTRIES" identifier . This identifiers is of the category "OTHER".




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