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General NPI Number Information
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NPI Number | 1154988418
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Entity Type | Organization
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Legal Business Name | LIBERTY LAKE FOOT & ANKLE PLLC
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Dates
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Enumeration Date | 05/22/2019
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Last Update Date | 05/22/2019
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Provider Practice Location Address
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Address Line | 23505 E APPLEWAY AVE STE 104
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-6003
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Country | US
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Telephone | 509-742-0093
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Fax |
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Provider Business Mailing Address
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Address Line | 23505 E APPLEWAY AVE STE 104
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-6003
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Country | US
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Telephone | 509-742-0093
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Fax |
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Authorized Official
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Title or Position | DPM
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Name | KEVIN DOW
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Credential | DPM
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Telephone | 509-742-0093
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP1100X
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Taxonomy Name | Podiatric Clinic/Center
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License Number |
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License Number State |
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