Healthcare Provider Details

I. General information

NPI: 1699286724
Provider Name (Legal Business Name): IDEAL OPTION, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W MAIN ST STE 405
WALLA WALLA WA
99362-2837
US

IV. Provider business mailing address

8656 W GAGE BLVD STE 301B
KENNEWICK WA
99336-7145
US

V. Phone/Fax

Practice location:
  • Phone: 509-222-1275
  • Fax: 509-491-3031
Mailing address:
  • Phone: 509-222-1275
  • Fax: 509-491-3031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRIAN JEFFERSON DAWSON
Title or Position: CMO
Credential: MD
Phone: 509-222-1275