Basic Information
| Provider Information | |||||||||
| NPI: | 1417990888 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROLIANCE SURGEONS INC., P.S. | ||||||||
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| OtherOrganizationName: | STAR SPORTS THERAPY AND ATHLETIC REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 OLIVE WAY | ||||||||
| Address2: | SUITE 1505 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981011878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068382590 | ||||||||
| FaxNumber: | 2062648689 | ||||||||
| Practice Location | |||||||||
| Address1: | 8009 S 180TH ST | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980321042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252267827 | ||||||||
| FaxNumber: | 4252515757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | FITZGERALD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2068382599 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROLIANCE SURGEONS INC., P.S. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 601484763 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 601484763 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.