Healthcare Provider Details

I. General information

NPI: 1811726193
Provider Name (Legal Business Name): WASHINGTON STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N RIVERPOINT BLVD
SPOKANE WA
99202-1610
US

IV. Provider business mailing address

412 E SPOKANE FALLS BLVD
SPOKANE WA
99202-2131
US

V. Phone/Fax

Practice location:
  • Phone: 509-505-7481
  • Fax: 509-606-2515
Mailing address:
  • Phone: 509-505-7481
  • Fax: 509-606-2515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA BOCARDO
Title or Position: PRACTICE MANAGER
Credential:
Phone: 509-505-7481