Healthcare Provider Details

I. General information

NPI: 1265986376
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17130 AVONDALE WAY NE STE 111
REDMOND WA
98052-4455
US

IV. Provider business mailing address

17130 AVONDALE WAY NE STE 111
REDMOND WA
98052-4455
US

V. Phone/Fax

Practice location:
  • Phone: 425-885-6600
  • Fax: 425-885-6580
Mailing address:
  • Phone: 425-885-6600
  • Fax: 425-885-6580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number601484763
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number601484763
License Number StateWA

VIII. Authorized Official

Name: CORI M. PLEASANT
Title or Position: MGR PROVIDER RELATIONS/ENROLLMENT
Credential:
Phone: 206-838-2585