=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992149777
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. HOLLY RENEE CORDERO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2013
-----------------------------------------------------
Last Update Date | 04/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13224 E TALL TREE RD
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99216-2411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-924-1506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13224 E TALL TREE RD
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99216-2411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-924-1506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 364500
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------