Healthcare Provider Details

I. General information

NPI: 1346889094
Provider Name (Legal Business Name): JARED FLATTUM STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2019
Last Update Date: 12/28/2019
Certification Date: 12/28/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HAWTHORNE RD
SPOKANE WA
99251-2515
US

IV. Provider business mailing address

9803 N IVANHOE RD
SPOKANE WA
99218-2217
US

V. Phone/Fax

Practice location:
  • Phone: 509-777-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: