MEDICARE: LOWER COLUMBIA AMBULATORY SURGERY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center		WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	147562	OTHER	WA	L&I
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710927553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOWER COLUMBIA AMBULATORY SURGERY CENTER

Provider Business Mailing Address
First Line	:	820 11TH AVE
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2402
Country	:	US
Telephone Number	:	360-423-0960
Fax Number	:	360-423-8778

Provider Business Practice Location Address
First Line	:	820 11TH AVE
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2402
Country	:	US
Telephone Number	:	360-423-0960
Fax Number	:	360-423-8778

Authorized Official
Title or Position	:	OWNER
Name	:	ALEXANDER IEROKOMOS
Credential	:	MD
Telephone Number	:	360-423-0960

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	02/29/2008

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