Healthcare Provider Details

I. General information

NPI: 1316914278
Provider Name (Legal Business Name): HARBOR ENDOSCOPY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 POINT FOSDICK DR NW 308
GIG HARBOR WA
98335-1706
US

IV. Provider business mailing address

1112 6TH AVE 200
TACOMA WA
98405-4040
US

V. Phone/Fax

Practice location:
  • Phone: 253-272-8664
  • Fax: 253-404-1352
Mailing address:
  • Phone: 253-272-8664
  • Fax: 253-404-1352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberASF.FX.60100031
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License NumberFX00057739
License Number StateWA

VIII. Authorized Official

Name: JOHN G CARROUGHER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 253-272-8664