Provider Demographics
NPI:1508352881
Name:PROFESSIONAL RECREATION ORGANIZATION, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL RECREATION ORGANIZATION, INC.
Other - Org Name:PRO SPORTS CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL BILLING & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-895-6575
Mailing Address - Street 1:4455 148TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3120
Mailing Address - Country:US
Mailing Address - Phone:425-869-4746
Mailing Address - Fax:425-869-5285
Practice Address - Street 1:4455 148TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3120
Practice Address - Country:US
Practice Address - Phone:425-869-4746
Practice Address - Fax:425-869-5285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600541508207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty