Provider Demographics
NPI:1760847081
Name:QLIANCE MEDICAL GROUP OF WASHINGTON
Entity Type:Organization
Organization Name:QLIANCE MEDICAL GROUP OF WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:1877-754-2623
Mailing Address - Street 1:521 2ND PL N
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-4537
Mailing Address - Country:US
Mailing Address - Phone:253-478-4900
Mailing Address - Fax:
Practice Address - Street 1:521 2ND PL N
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4537
Practice Address - Country:US
Practice Address - Phone:253-478-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60608139261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center