Provider Demographics
NPI:1750321006
Name:PROLIANCE SURGEONS, INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S.
Other - Org Name:PROLIANCE ORTHOPEDIC ASSOCIATES AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF RISK OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-838-2590
Mailing Address - Street 1:4033 TALBOT RD S STE 270
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5767
Mailing Address - Country:US
Mailing Address - Phone:425-226-2041
Mailing Address - Fax:
Practice Address - Street 1:4033 TALBOT RD S STE 270
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5767
Practice Address - Country:US
Practice Address - Phone:425-226-2041
Practice Address - Fax:425-226-2405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB07431Medicare PIN