Healthcare Provider Details

I. General information

NPI: 1780610220
Provider Name (Legal Business Name): PROLIANCE SURGEONS INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 27TH AVE SE
PUYALLUP WA
98374-1145
US

IV. Provider business mailing address

PO BOX 1205
PUYALLUP WA
98371-0231
US

V. Phone/Fax

Practice location:
  • Phone: 253-770-9000
  • Fax: 253-770-9712
Mailing address:
  • Phone: 253-770-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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