1588802466 NPI number — SALMON CREEK PLASTIC SURGERY PC

Table of content: (NPI 1588802466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588802466 NPI number — SALMON CREEK PLASTIC SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALMON CREEK PLASTIC SURGERY PC
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:
1588802466
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13712 NE 10TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-823-0860
Provider Business Mailing Address Fax Number:
360-828-1407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13712 NE 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-823-0860
Provider Business Practice Location Address Fax Number:
360-828-1407
Provider Enumeration Date:
01/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
K
Authorized Official Title or Position:
BUSINESS OWNER / PLASTIC SURGEON
Authorized Official Telephone Number:
360-823-0860

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X , with the licence number: 602673506 , 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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