1942645072 NPI number — REBECCA MICHELLE COCKLEREECE LMP

Table of content: REBECCA MICHELLE COCKLEREECE LMP (NPI 1942645072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942645072 NPI number — REBECCA MICHELLE COCKLEREECE LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COCKLEREECE
Provider First Name:
REBECCA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON
Provider Other First Name:
REBECCA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942645072
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28719 W LONG LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99013-9502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-868-6256
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13701 E SPRAGUE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99216-0811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-922-5585
Provider Business Practice Location Address Fax Number:
509-927-7336
Provider Enumeration Date:
05/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA00019356 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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