=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083732440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL WEIGHT LOSS CLINIC OF EASTERN WASHINGTON PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1075 JADWIN AVE SUITE 203
-----------------------------------------------------
City | RICHLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99352-3437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-943-0710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1075 JADWIN AVE SUITE 203
-----------------------------------------------------
City | RICHLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99352-3437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-943-0710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER &SURGEON
-----------------------------------------------------
Name | DR. EARL ROSS FOX
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 509-943-0710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------