Provider Demographics
NPI:1093960700
Name:PROLIANCE SURGEONS, INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S.
Other - Org Name:PROLIANCE HIGHLANDS SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF RISK OFFICER
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 100
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:425-507-0800
Mailing Address - Fax:425-507-0805
Practice Address - Street 1:510 8TH AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-5436
Practice Address - Country:US
Practice Address - Phone:425-507-0800
Practice Address - Fax:425-507-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA612815303OtherOWCP
WA246464OtherWA LABOR & INDUSTRIES
WA2000432Medicaid