Basic Information
| Provider Information | |||||||||
| NPI: | 1790744175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN WASHINGTON ENDOSCOPY CENTERS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PUYALLUP ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2157 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984012157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538413933 | ||||||||
| FaxNumber: | 2538648412 | ||||||||
| Practice Location | |||||||||
| Address1: | 1703 S MERIDIAN | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538413933 | ||||||||
| FaxNumber: | 2538648412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | CON 1301 REQUIRED | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7137326 | 05 | WA | MEDICAID |