MEDICARE: MICHAEL VICTOR NOWACK D.P.T

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT00009579	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0201431	OTHER	WA	LABOR AND INDUSTRIES

General Provider Information

NPI Number	:	1407940497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL VICTOR NOWACK D.P.T

Provider Business Mailing Address
First Line	:	PO BOX 3482
Second Line	:
City	:	POST FALLS
State	:	ID
Zip	:	83877-3482
Country	:	US
Telephone Number	:	208-209-6170
Fax Number	:	208-209-6169

Provider Business Practice Location Address
First Line	:	6186 W MAINE
Second Line	:
City	:	SPIRIT LAKE
State	:	ID
Zip	:	83869
Country	:	US
Telephone Number	:	208-623-6717
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	11/30/2015

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