Healthcare Provider Details

I. General information

NPI: 1043407935
Provider Name (Legal Business Name): LIBERTY LAKE FAMILY & SPORTS MEDICINE, P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2207 N MOLTER RD STE 101
LIBERTY LAKE WA
99019-7571
US

IV. Provider business mailing address

2207 N MOLTER RD STE 101
LIBERTY LAKE WA
99019-7571
US

V. Phone/Fax

Practice location:
  • Phone: 509-921-7755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number601991291
License Number StateWA

VIII. Authorized Official

Name: TIMOTHY MANSON
Title or Position: OWNER
Credential:
Phone: 509-921-7755