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General NPI Number Information
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NPI Number | 1043407935
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Entity Type | Organization
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Legal Business Name | LIBERTY LAKE FAMILY & SPORTS MEDICINE, P.S.
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Dates
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Enumeration Date | 09/25/2007
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Last Update Date | 10/04/2011
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Provider Practice Location Address
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Address Line | 2207 N MOLTER RD STE 101
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-7571
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Country | US
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Telephone | 509-921-7755
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Fax |
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Provider Business Mailing Address
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Address Line | 2207 N MOLTER RD STE 101
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-7571
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TIMOTHY MANSON
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Credential |
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Telephone | 509-921-7755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 601991291
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License Number State | WA
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