Healthcare Provider Details

I. General information

NPI: 1124981832
Provider Name (Legal Business Name): WSK12 ENTERPRISE GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W MAIN AVE
SPOKANE WA
99201-0643
US

IV. Provider business mailing address

707 W MAIN AVE
SPOKANE WA
99201-0643
US

V. Phone/Fax

Practice location:
  • Phone: 509-475-0249
  • Fax:
Mailing address:
  • Phone: 509-475-0249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: NATHANIEL L WITHEROW
Title or Position: OFFICE MANAGER
Credential:
Phone: 509-475-0249