Provider Demographics
NPI:1710927553
Name:LOWER COLUMBIA AMBULATORY SURGERY CENTER
Entity Type:Organization
Organization Name:LOWER COLUMBIA AMBULATORY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:IEROKOMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-423-0960
Mailing Address - Street 1:820 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2402
Mailing Address - Country:US
Mailing Address - Phone:360-423-0960
Mailing Address - Fax:360-423-8778
Practice Address - Street 1:820 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2402
Practice Address - Country:US
Practice Address - Phone:360-423-0960
Practice Address - Fax:360-423-8778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA147562OtherL&I
WA7134463Medicaid
WA147562OtherL&I