Provider Demographics
NPI:1457412017
Name:ARTISTIC PLASTIC SURGERY CENTER PLLC
Entity Type:Organization
Organization Name:ARTISTIC PLASTIC SURGERY CENTER PLLC
Other - Org Name:ARTISTIC PLASTIC SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-756-0933
Mailing Address - Street 1:3515 S 15TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1952
Mailing Address - Country:US
Mailing Address - Phone:253-756-0933
Mailing Address - Fax:253-759-6553
Practice Address - Street 1:3515 S 15TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1952
Practice Address - Country:US
Practice Address - Phone:253-756-0933
Practice Address - Fax:253-759-6553
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHSTAR SURGICAL SERVICES, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602804600208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA=========OtherTAX ID