1851672752 NPI number — THE AESTHETIC SURGERY CENTRE, PLLC

Table of content: (NPI 1851672752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851672752 NPI number — THE AESTHETIC SURGERY CENTRE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE AESTHETIC SURGERY CENTRE, 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:
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:
1851672752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2202 S CEDAR ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-2318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-627-2900
Provider Business Mailing Address Fax Number:
253-627-2941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34503 9TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-8727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-838-3657
Provider Business Practice Location Address Fax Number:
253-838-7134
Provider Enumeration Date:
09/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PRATT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
253-627-2900

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  601963666 , 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)

  • Identifier: 7131055 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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