=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538244017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPIRE STAR VENTURES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 08/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12410 E SINTO AVE SUITE 203
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99216-2199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-927-7827
-----------------------------------------------------
Fax | 509-928-7556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12410 E SINTO AVE SUITE 203
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99216-2199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-927-7827
-----------------------------------------------------
Fax | 509-928-7556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | MR. STEPHEN NORMAN SCHAEFER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 509-467-1244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------