Healthcare Provider Details

I. General information

NPI: 1326672692
Provider Name (Legal Business Name): EXCELSIOR INTEGRATED CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 W. INDIAN TRAIL RD
SPOKANE WA
99208-4739
US

IV. Provider business mailing address

3754 W INDIAN TRAIL RD
SPOKANE WA
99208-4736
US

V. Phone/Fax

Practice location:
  • Phone: 509-559-3100
  • Fax: 509-328-7582
Mailing address:
  • Phone: 509-559-3100
  • Fax: 509-328-7582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DOVIE BRITTON
Title or Position: CONTRACTING AND CREDENTIALING COORD
Credential:
Phone: 509-559-3132