1104151562 NPI number — EAR NOSE THROAT & PLASTIC SURGERY ASSOCIATES OF THE SOUTH SOUND PS

Table of content: (NPI 1104151562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104151562 NPI number — EAR NOSE THROAT & PLASTIC SURGERY ASSOCIATES OF THE SOUTH SOUND PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAR NOSE THROAT & PLASTIC SURGERY ASSOCIATES OF THE SOUTH SOUND PS
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:
6
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:
1104151562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 6TH ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98002-4342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-833-6241
Provider Business Mailing Address Fax Number:
253-833-4113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1609 S MERIDIAN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98371-7517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-833-6241
Provider Business Practice Location Address Fax Number:
253-833-4113
Provider Enumeration Date:
10/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PUIG
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
253-833-6241

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  ASFFS60101770 , 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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