Provider Demographics
NPI:1912198748
Name:VANCOUVER EAR, NOSE & THROAT HEAD & NECK SURGERY CLINIC, PS
Entity Type:Organization
Organization Name:VANCOUVER EAR, NOSE & THROAT HEAD & NECK SURGERY CLINIC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GEIGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-449-6612
Mailing Address - Street 1:1405 SE 164TH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9644
Mailing Address - Country:US
Mailing Address - Phone:360-256-4425
Mailing Address - Fax:360-260-7249
Practice Address - Street 1:14411 NE 20TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-6431
Practice Address - Country:US
Practice Address - Phone:360-256-4425
Practice Address - Fax:360-260-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7068596Medicaid