Healthcare Provider Details

I. General information

NPI: 1750481453
Provider Name (Legal Business Name): LONGVIEW SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 9TH AVE SUITE #110
LONGVIEW WA
98632
US

IV. Provider business mailing address

625 9TH AVE STE 110
LONGVIEW WA
98632-2465
US

V. Phone/Fax

Practice location:
  • Phone: 360-442-7900
  • Fax: 360-442-7901
Mailing address:
  • Phone: 360-442-7913
  • Fax: 360-442-7901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number602313328
License Number StateWA

VIII. Authorized Official

Name: MRS. JENNIFER L MYERS
Title or Position: DIRECTOR OF CLIENT SERVICES
Credential:
Phone: 360-442-7913