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General NPI Number Information
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NPI Number | 1558071126
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Entity Type | Organization
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Legal Business Name | THE LORD'S GYM VANCOUVER USA
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Dates
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Enumeration Date | 12/05/2022
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Last Update Date | 12/05/2022
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Provider Practice Location Address
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Address Line | 2410 GRAND BLVD
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City | VANCOUVER
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State | WA
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Zip | 98661
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Country | US
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Telephone | 360-718-7279
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Fax |
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Provider Business Mailing Address
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Address Line | P.O. BOX 2275
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City | VANCOUVER
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State | WA
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Zip | 98668
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Country | US
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Telephone | 360-718-7279
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Fax |
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Authorized Official
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Title or Position | BOOKKEEPER/TREASURER
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Name | NICOLE MICHELLE TURNER
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Credential |
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Telephone | 360-903-3911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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