Healthcare Provider Details

I. General information

NPI: 1255903720
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 168TH PLACE SE SUITE 201
COVINGTON WA
98042-4902
US

IV. Provider business mailing address

4011 TALBOT RD S STE 300
RENTON WA
98055-5791
US

V. Phone/Fax

Practice location:
  • Phone: 253-630-3660
  • Fax: 253-631-1591
Mailing address:
  • Phone: 425-656-5060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA KLEISLE
Title or Position: CHIEF RISK OFFICER
Credential:
Phone: 206-838-2590