1093265951 NPI number — IDEAL OPTION, PLLC

Table of content: (NPI 1093265951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093265951 NPI number — IDEAL OPTION, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDEAL OPTION, 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:
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:
1093265951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8656 W GAGE BLVD
Provider Second Line Business Mailing Address:
SUITE 301B
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-7145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-222-1275
Provider Business Mailing Address Fax Number:
509-491-3031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6208 N COLTON ST
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:
99208-8100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-413-2112
Provider Business Practice Location Address Fax Number:
509-413-2855
Provider Enumeration Date:
10/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DAWSON
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
JEFFERSON
Authorized Official Title or Position:
CMO
Authorized Official Telephone Number:
509-222-1275

Provider Taxonomy Codes

  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2031254 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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