1053366807 NPI number — SPOKANE EAR NOSE AND THROAT CLINIC

Table of content: (NPI 1053366807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053366807 NPI number — SPOKANE EAR NOSE AND THROAT CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPOKANE EAR NOSE AND THROAT CLINIC
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:
6
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:
1053366807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 W CATALDO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99201-2217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 W CATALDO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99201-2217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-624-2326
Provider Business Practice Location Address Fax Number:
509-744-3040
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHACKELFORD
Authorized Official First Name:
DIRENDIA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGED CARE SPECIALIST
Authorized Official Telephone Number:
800-654-0889

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  MD00031255 , 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)

  • Identifier: 4931893 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8151235 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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