=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780755876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VANCOUVER ENT AND ENT OF THE NORTHWEST PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2006
-----------------------------------------------------
Last Update Date | 05/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1405 SE 164TH AVE SUITE 102
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-9644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-256-4425
-----------------------------------------------------
Fax | 360-256-2474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1405 SE 164TH AVE SUITE 102
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-9644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-256-4425
-----------------------------------------------------
Fax | 360-254-1844
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MRS. STEPHANIE HANKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-256-4425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 602 593 569
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------