Healthcare Provider Details

I. General information

NPI: 1982058814
Provider Name (Legal Business Name): NW INTERVENTIONAL MEDICINE AND ORTHOPEDIC REHAB PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11802 NE 65TH ST.
VANCOUVER WA
98662
US

IV. Provider business mailing address

11802 NE 65TH ST.
VANCOUVER WA
98662
US

V. Phone/Fax

Practice location:
  • Phone: 360-253-6883
  • Fax: 360-892-7040
Mailing address:
  • Phone: 360-253-6883
  • Fax: 360-892-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MIKE BACK
Title or Position: OWNER/MANAGER
Credential: DC
Phone: 360-253-6883