Provider Demographics
NPI: | 1437541620 |
---|---|
Name: | SB SURGICAL ASSISTANT, LLC |
Entity Type: | Organization |
Organization Name: | SB SURGICAL ASSISTANT, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | STACI |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BOTTLES |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | RN |
Authorized Official - Phone: | 360-445-3030 |
Mailing Address - Street 1: | PO BOX 803 |
Mailing Address - Street 2: | |
Mailing Address - City: | CONWAY |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98238-0803 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-445-3003 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 20659 BULSON RD |
Practice Address - Street 2: | |
Practice Address - City: | MOUNT VERNON |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98274-8032 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-445-3030 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-02-24 |
Last Update Date: | 2015-02-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | RN00110231 | 163WR0006X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 163WR0006X | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | Group - Single Specialty |