1730456971 NPI number — PACIFIC SURGICAL WEIGHT LOSS CENTER, PLLC

Table of content: (NPI 1730456971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730456971 NPI number — PACIFIC SURGICAL WEIGHT LOSS CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC SURGICAL WEIGHT LOSS CENTER, PLLC
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:
1730456971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 LILLY RD NE
Provider Second Line Business Mailing Address:
SUITE C-2
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98506-5427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-412-3120
Provider Business Mailing Address Fax Number:
360-412-1046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 LILLY RD NE
Provider Second Line Business Practice Location Address:
STE. C-2
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-412-3120
Provider Business Practice Location Address Fax Number:
360-412-1046
Provider Enumeration Date:
11/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HENDERSON
Authorized Official First Name:
JACKIE
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE STAFF
Authorized Official Telephone Number:
360-412-3120

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD00036124 , 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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