1316040405 NPI number — SURGERY CENTER OF OLYMPIA LLC

Table of content: (NPI 1316040405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316040405 NPI number — SURGERY CENTER OF OLYMPIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGERY CENTER OF OLYMPIA 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:
SOUTH SOUND SURGERY CENTER
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:
1316040405
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3430 PACIFIC AVE SE
Provider Second Line Business Mailing Address:
A6 PMB 411
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98501-2176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-486-6300
Provider Business Mailing Address Fax Number:
360-493-4242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 PROVIDENCE LN NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-6927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-486-6300
Provider Business Practice Location Address Fax Number:
360-493-4242
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOUSER
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
360-486-6303

Provider Taxonomy Codes

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

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





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