Healthcare Provider Details

I. General information

NPI: 1962402503
Provider Name (Legal Business Name): NORTH KITSAP AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20669 BOND RD NE SUITE 200
POULSBO WA
98370-6525
US

IV. Provider business mailing address

20669 BOND RD NE SUITE 200
POULSBO WA
98370-6525
US

V. Phone/Fax

Practice location:
  • Phone: 360-779-6527
  • Fax: 360-697-2743
Mailing address:
  • Phone: 360-779-6527
  • Fax: 360-697-2743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number600558138
License Number StateWA

VIII. Authorized Official

Name: JAMIE FOWLER
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 360-779-6527