Healthcare Provider Details

I. General information

NPI: 1467451906
Provider Name (Legal Business Name): ALVA JACK CHILDRESS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 8TH AVE SUITE 1100
SPOKANE WA
99204-2307
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-4060
  • Fax: 509-474-6198
Mailing address:
  • Phone: 866-747-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD114350
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD60096557
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: