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General NPI Number Information
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NPI Number | 1982058814
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Entity Type | Organization
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Legal Business Name | NW INTERVENTIONAL MEDICINE AND ORTHOPEDIC REHAB PLLC
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Dates
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Enumeration Date | 04/18/2016
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Last Update Date | 04/18/2016
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Provider Practice Location Address
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Address Line | 11802 NE 65TH ST.
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City | VANCOUVER
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State | WA
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Zip | 98662
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Country | US
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Telephone | 360-253-6883
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Fax | 360-892-7040
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Provider Business Mailing Address
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Address Line | 11802 NE 65TH ST.
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City | VANCOUVER
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State | WA
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Zip | 98662
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Country | US
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Telephone | 360-253-6883
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Fax | 360-892-7040
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MIKE BACK
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Credential | DC
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Telephone | 360-253-6883
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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