Healthcare Provider Details

I. General information

NPI: 1114186459
Provider Name (Legal Business Name): LUAY D AILABOUNI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GOETHALS DRIVE, 2ND FLOOR KADLEC CLINIC GENERAL & COLORECTAL SURGERY
RICHLAND WA
99352-3304
US

IV. Provider business mailing address

560 GAGE BLVD SUITE 203
RICHLAND WA
99352-8650
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-3185
  • Fax: 509-946-1850
Mailing address:
  • Phone: 509-942-3627
  • Fax: 509-942-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD60323856
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD30623856
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: