Healthcare Provider Details

I. General information

NPI: 1831253426
Provider Name (Legal Business Name): SALMON CREEK PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13712 NE 10TH AVE
VANCOUVER WA
98685-2628
US

IV. Provider business mailing address

13712 NE 10TH AVE
VANCOUVER WA
98685-2628
US

V. Phone/Fax

Practice location:
  • Phone: 360-823-0860
  • Fax: 360-828-1407
Mailing address:
  • Phone: 360-823-0860
  • Fax: 360-828-1407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD KENNETH GREEN JR.
Title or Position: PHYSICIAN AND OWNER
Credential: M.D.
Phone: 360-574-7622