Healthcare Provider Details

I. General information

NPI: 1437105368
Provider Name (Legal Business Name): PROLIANCE SURGEONS INC P S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S LAVENTURE RD
MOUNT VERNON WA
98274-6033
US

IV. Provider business mailing address

1401 S LAVENTURE RD
MOUNT VERNON WA
98274-6033
US

V. Phone/Fax

Practice location:
  • Phone: 360-424-7041
  • Fax: 360-424-2418
Mailing address:
  • Phone: 360-424-7041
  • Fax: 360-424-2418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number601484763
License Number StateWA

VIII. Authorized Official

Name: CORI M. PLEASANT
Title or Position: DEL CRED & ENROLLMENT MANAGER
Credential:
Phone: 206-838-2585