Provider Demographics
NPI:1083752042
Name:PROLIANCE SURGEONS INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS INC., P.S.
Other - Org Name:PROLIANCE SPORTS THERAPY AND REHAB OF ISSAQUAH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF RISK OFFICIER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-838-2590
Mailing Address - Street 1:510 8TH AVE NE STE 320
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-5436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 8TH AVE NE STE 340
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-5449
Practice Address - Country:US
Practice Address - Phone:425-313-3051
Practice Address - Fax:425-313-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763225100000X, 225X00000X
225100000X, 2251H1200X, 225X00000X, 225XH1200X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA153519OtherWA LABOR & INDUSTRIES
WA0532700007Medicare NSC