1912934878 NPI number — CCA OF SPOKANE, LLC

Table of content: (NPI 1912934878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912934878 NPI number — CCA OF SPOKANE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCA OF SPOKANE, LLC
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:
1912934878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 W 7TH AVE
Provider Second Line Business Mailing Address:
STE 540
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99204-2349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-232-0567
Provider Business Mailing Address Fax Number:
509-232-0571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 W 7TH AVE
Provider Second Line Business Practice Location Address:
STE 540
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-232-0567
Provider Business Practice Location Address Fax Number:
509-232-0571
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COMBS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
509-232-0567

Provider Taxonomy Codes

  • Taxonomy code: 293D00000X , with the licence number:  FX00057836 , 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: 806709200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00077314 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7120652 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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