1194903294 NPI number — SOUTH SOUND LASER SERVICES LLC

Table of content: (NPI 1194903294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194903294 NPI number — SOUTH SOUND LASER SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SOUND LASER SERVICES LLC
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:
Provider Other Organization Name Type Code:
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:
1194903294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6339 E SPEEDWAY BLVD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85710-1147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-323-8732
Provider Business Mailing Address Fax Number:
520-547-1865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 7TH AVE
Provider Second Line Business Practice Location Address:
SUITE 116 #125
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98101-1397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-547-4130
Provider Business Practice Location Address Fax Number:
520-258-0304
Provider Enumeration Date:
01/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EVANOSKI
Authorized Official First Name:
MARY ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANANGER
Authorized Official Telephone Number:
520-547-4130

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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