1295114346 NPI number — WANDERMERE OCCUPATIONAL MEDICINE PLLC

Table of content: (NPI 1295114346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295114346 NPI number — WANDERMERE OCCUPATIONAL MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WANDERMERE OCCUPATIONAL MEDICINE 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:
1295114346
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5011 W ALCOTT CT
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:
99208-9141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-879-0039
Provider Business Mailing Address Fax Number:
509-466-4798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 E FARWELL RD
Provider Second Line Business Practice Location Address:
SUITE204
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99218-8210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-720-7452
Provider Business Practice Location Address Fax Number:
509-466-4798
Provider Enumeration Date:
05/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DEPNER
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
509-879-0039

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X , with the licence number:  PA10001774 , 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)





Copyright © 2007-2025 www.npivalidator.com