Basic Information
| Provider Information | |||||||||
| NPI: | 1962427880 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | N.A.T.I.V.E. PROJECT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | N.A.T.I.V.E. HEALTH OF SPOKANE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1803 W MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093255502 | ||||||||
| FaxNumber: | 5094839460 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 E NORTH FOOTHILLS DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992072101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094837535 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LODGE | ||||||||
| AuthorizedOfficialFirstName: | TONI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5093255502 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L0131351 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1104811033 | 01 | WA | NPI SANDRA FORSMAN | OTHER | 1306842596 | 01 | WA | NPI VINETTA MACPHERSON | OTHER | 1912996257 | 01 | WA | NPI CANDY JACKSON | OTHER | 1982600359 | 01 | WA | NPI KENDRA LONG | OTHER |