Basic Information
Provider Information
NPI: 1003140377
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KINCH
FirstName: DALLAS
MiddleName: CHRISTIAN
NamePrefix:  
NameSuffix:  
Credential: L.M.P.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2381 S SOUTHEAST BLVD
Address2: APARTMENT 3
City: SPOKANE
State: WA
PostalCode: 992034551
CountryCode: US
TelephoneNumber: 5093385982
FaxNumber:  
Practice Location
Address1: 3022 E 57TH AVE
Address2: SUITE 14
City: SPOKANE
State: WA
PostalCode: 992237033
CountryCode: US
TelephoneNumber: 5093385982
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/19/2009
LastUpdateDate: 03/06/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225700000XMA60084236WAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist 

No ID Information.


Home