Basic Information
| Provider Information | |||||||||
| NPI: | 1477025930 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPOKANE REHAB & PAIN CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 N DIVISION ST | ||||||||
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| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992021899 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 5093218447 | ||||||||
| Practice Location | |||||||||
| Address1: | 1315 N DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992021899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098086265 | ||||||||
| FaxNumber: | 5093218447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2018 | ||||||||
| LastUpdateDate: | 12/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRICK | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5098086265 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, OT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.