Healthcare Provider Details

I. General information

NPI: 1023394210
Provider Name (Legal Business Name): PROVIDENCE PHYSICIAN SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 E HAWTHORNE RD
SPOKANE WA
99218-1417
US

IV. Provider business mailing address

PO BOX 34439
SEATTLE WA
98124-1439
US

V. Phone/Fax

Practice location:
  • Phone: 509-252-1900
  • Fax: 509-465-4105
Mailing address:
  • Phone: 509-474-2072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KATLYN LEE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 509-474-7159