Healthcare Provider Details

I. General information

NPI: 1629395397
Provider Name (Legal Business Name): PROVIDENCE PHYSICIAN SERVICES CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W 8TH AVE 454 E
SPOKANE WA
99204-2302
US

IV. Provider business mailing address

101 W 8TH AVE MOTHER GAMELIN CENTER, 3RD FLOOR
SPOKANE WA
99204-2307
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-3810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANSELMO NUNEZ
Title or Position: CHIEF EXECUTIVE
Credential:
Phone: 509-474-6616