Healthcare Provider Details

I. General information

NPI: 1710927553
Provider Name (Legal Business Name): LOWER COLUMBIA AMBULATORY SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 11TH AVE
LONGVIEW WA
98632-2402
US

IV. Provider business mailing address

820 11TH AVE
LONGVIEW WA
98632-2402
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-0960
  • Fax: 360-423-8778
Mailing address:
  • Phone: 360-423-0960
  • Fax: 360-423-8778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateWA

VIII. Authorized Official

Name: ALEXANDER IEROKOMOS
Title or Position: OWNER
Credential: MD
Phone: 360-423-0960