Provider Demographics
NPI:1720237910
Name:PACELINE ANESTHESIA LLC
Entity Type:Organization
Organization Name:PACELINE ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SIAPCO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:253-588-7911
Mailing Address - Street 1:2100 LITTLE MT LANE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274
Mailing Address - Country:US
Mailing Address - Phone:360-416-6735
Mailing Address - Fax:360-424-6924
Practice Address - Street 1:3819 100TH ST SW
Practice Address - Street 2:SUITE 7-C
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4470
Practice Address - Country:US
Practice Address - Phone:253-588-7911
Practice Address - Fax:253-984-6774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9656489Medicaid
WA9656489Medicaid