Provider Demographics
NPI:1417499575
Name:PROLIANCE SURGEONS, INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S.
Other - Org Name:PROLIANCE REHABILITATION, SPORTS AND SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR PROVIDER RELATIONS/ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:CORI
Authorized Official - Middle Name:M
Authorized Official - Last Name:PLEASANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-838-2585
Mailing Address - Street 1:7320 216TH ST SW STE 320
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8006
Mailing Address - Country:US
Mailing Address - Phone:425-673-3900
Mailing Address - Fax:425-252-4788
Practice Address - Street 1:3216 NORTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4290
Practice Address - Country:US
Practice Address - Phone:425-252-4700
Practice Address - Fax:425-252-4788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763208100000X
261Q00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA49391OtherWA LABOR & INDUSTRIES
WA1043983Medicaid