1962493007 NPI number — COLONIAL CLINIC II, LLC

Table of content: (NPI 1962493007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962493007 NPI number — COLONIAL CLINIC II, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL CLINIC II, 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:
1962493007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 N WASHINGTON ST
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99201-2202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-327-9831
Provider Business Mailing Address Fax Number:
509-327-9857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 N WASHINGTON ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99201-2202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-327-9831
Provider Business Practice Location Address Fax Number:
509-327-9857
Provider Enumeration Date:
10/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COLYAR
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
509-327-9831

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 32025500 . This is a "CHEMICAL DEPENDENCY TREAT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: J0HY6W00 . This is a "ONE HLTH. PORT ID." identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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