1417990888 NPI number — PROLIANCE SURGEONS INC., P.S.

Table of content: (NPI 1417990888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417990888 NPI number — PROLIANCE SURGEONS INC., P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROLIANCE SURGEONS INC., P.S.
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:
STAR SPORTS THERAPY AND ATHLETIC REHABILITATION
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:
1417990888
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 OLIVE WAY
Provider Second Line Business Mailing Address:
SUITE 1505
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98101-1878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-838-2590
Provider Business Mailing Address Fax Number:
206-264-8689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8009 S 180TH ST
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
KENT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98032-1042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-226-7827
Provider Business Practice Location Address Fax Number:
425-251-5757
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FITZGERALD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
206-838-2599

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  601484763 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 601484763 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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