Healthcare Provider Details

I. General information

NPI: 1992878763
Provider Name (Legal Business Name): NORTHWEST SPINE & SPORTS PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 112TH AVE NE SUITE D 258
BELLEVUE WA
98004-3752
US

IV. Provider business mailing address

1750 112TH AVE NE SUITE D 258
BELLEVUE WA
98004-3752
US

V. Phone/Fax

Practice location:
  • Phone: 425-451-2272
  • Fax: 425-451-1052
Mailing address:
  • Phone: 425-451-2272
  • Fax: 425-451-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number601873433
License Number StateWA

VIII. Authorized Official

Name: MS. TINA MARIE LEAVITT
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 425-451-2272