Basic Information
| Provider Information | |||||||||
| NPI: | 1760421846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EVERETT BONE AND JOINT SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 PACIFIC AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253392433 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 PACIFIC AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253178535 | ||||||||
| FaxNumber: | 4253178628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | KLEISLE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF RISK OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2068382590 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 601484763 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2093710 | 05 | WA | MEDICAID | 137868 | 01 | WA | WA LABOR & INDUSTRIES | OTHER |