Healthcare Provider Details

I. General information

NPI: 1457350712
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 CONTINENTAL PL
MOUNT VERNON WA
98273-4105
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 Number601 484 763
License Number StateWA

VIII. Authorized Official

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