1396785911 NPI number — INFECTIOUS DISEASE CLINIC OF SPOKANE

Table of content: (NPI 1396785911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396785911 NPI number — INFECTIOUS DISEASE CLINIC OF SPOKANE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFECTIOUS DISEASE CLINIC OF SPOKANE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396785911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21980 E COUNTRY VISTA DR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
LIBERTY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99019-6025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-926-1770
Provider Business Mailing Address Fax Number:
509-228-9542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 W 5TH AVE
Provider Second Line Business Practice Location Address:
#200 WEST
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204-4880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-353-3960
Provider Business Practice Location Address Fax Number:
509-343-0134
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOTT
Authorized Official First Name:
ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNT MANAGER
Authorized Official Telephone Number:
509-926-1770

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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