Basic Information
| Provider Information | |||||||||
| NPI: | 1467902957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONSECA | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | JOSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3649 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992203649 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 122 E MONTGOMERY AVE STE D | ||||||||
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| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992072219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098382531 | ||||||||
| FaxNumber: | 5097556580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2016 | ||||||||
| LastUpdateDate: | 10/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT60336583 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.