1245405224 NPI number — THERASPORT NORTHWEST, INC

Table of content: (NPI 1245405224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245405224 NPI number — THERASPORT NORTHWEST, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERASPORT NORTHWEST, INC
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:
1245405224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 E ROWAN AVE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99207-1214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-484-0095
Provider Business Mailing Address Fax Number:
509-484-0477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 E ROWAN AVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99207-1214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-484-0095
Provider Business Practice Location Address Fax Number:
509-484-0477
Provider Enumeration Date:
04/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
509-484-0095

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00002905 , 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: 7100431 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17438 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1104041458 . This is a "INDIVIDUAL PROVIDER NPI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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