Healthcare Provider Details

I. General information

NPI: 1902195597
Provider Name (Legal Business Name): ROB MILDES P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14315 E TALLMAN RD
CHATTAROY WA
99003-9507
US

IV. Provider business mailing address

14315 E TALLMAN RD P.O. BOX 517
CHATTAROY WA
99003-9507
US

V. Phone/Fax

Practice location:
  • Phone: 509-238-3020
  • Fax:
Mailing address:
  • Phone: 509-238-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberPT00005790
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: