Healthcare Provider Details

I. General information

NPI: 1417507963
Provider Name (Legal Business Name): ALEX MOFFITT TOBOSA RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 8TH AVE
SPOKANE WA
99204-2307
US

IV. Provider business mailing address

101 W 8TH AVE
SPOKANE WA
99204-2364
US

V. Phone/Fax

Practice location:
  • Phone: 509-414-3131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI61005859
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: