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
StateLicense IDTaxonomies
WARN00110231163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Single Specialty