1114263225 NPI number — DAVID C. WYNECOOP, MEMORIAL CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114263225 NPI number — DAVID C. WYNECOOP, MEMORIAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID C. WYNECOOP, MEMORIAL 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:
1114263225
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
928 E ILLINOIS 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:
99207-2637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-258-4517
Provider Business Mailing Address Fax Number:
509-258-6757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
928 E ILLINOIS 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:
99207-2637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-258-4517
Provider Business Practice Location Address Fax Number:
509-258-6757
Provider Enumeration Date:
12/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DELAY
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
LOU
Authorized Official Title or Position:
CLINICAL NURSE
Authorized Official Telephone Number:
509-258-4517

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  RN00147960 , 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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