1770013443 NPI number — INLAND NORTHWEST SURGERY CENTER PLLC

Table of content: (NPI 1770013443)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770013443 NPI number — INLAND NORTHWEST SURGERY CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:
INLAND NORTHWEST SURGERY CENTER PLLC

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:
FAMILY FOOT CENTER

Provider Other Organization Name Type Code:
3

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:
1770013443

Entity Type Code:
Organization

Replacement NPI:

Last Update Date:
06/15/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
526 N MULLAN RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
SPOKANE VALLEY

Provider Business Mailing Address State Name:
WA

Provider Business Mailing Address Postal Code:
99206-2408

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
509-924-2600

Provider Business Mailing Address Fax Number:
509-926-9865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
229 S 7TH ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
ST MARIES

Provider Business Practice Location Address State Name:
ID

Provider Business Practice Location Address Postal Code:
83861-1803

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
509-924-2600

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
06/15/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LUNDSTROM

Authorized Official First Name:
TRENA

Authorized Official Middle Name:

Authorized Official Title or Position:
MANAGER

Authorized Official Telephone Number:
509-924-2600

Provider Taxonomy Codes

Taxonomy code: 213E00000X , with the licence number: P-224 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Taxonomy code: 261QA1903X , with the licence number: 6011706837 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .