Healthcare Provider Details

I. General information

NPI: 1487183000
Provider Name (Legal Business Name): SOUTH SOUND AMBULATORY SURGERY CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 ENSIGN RD NE STE 310
OLYMPIA WA
98506-5063
US

IV. Provider business mailing address

3425 ENSIGN RD NE STE 310
OLYMPIA WA
98506-5063
US

V. Phone/Fax

Practice location:
  • Phone: 360-456-5678
  • Fax: 360-456-1238
Mailing address:
  • Phone: 360-456-5678
  • Fax: 360-456-1238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number601803289
License Number StateWA

VIII. Authorized Official

Name: JOSEPH C MULREAN
Title or Position: CO-OWNER
Credential: DMD
Phone: 360-456-5678