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General NPI Number Information
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NPI Number | 1205011889
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Entity Type | Organization
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Legal Business Name | PALOUSE FOOT & ANKLE CLINIC
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Dates
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Enumeration Date | 01/02/2008
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Last Update Date | 01/24/2008
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Provider Practice Location Address
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Address Line | 619 S WASHINGTON ST 103
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City | MOSCOW
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State | ID
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Zip | 83843-3090
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Country | US
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Telephone | 208-882-8939
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Fax | 509-334-0380
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Provider Business Mailing Address
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Address Line | 825 SE BISHOP BLVD 801
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City | PULLMAN
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State | WA
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Zip | 99163-5517
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Country | US
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Telephone | 208-882-8939
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Fax | 509-334-0380
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Authorized Official
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Title or Position | OWNER
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Name | BRAD J CAPAWANA
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Credential | DPM
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Telephone | 509-334-4498
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 1298150002
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License Number State | ID
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