Provider Demographics
NPI:1003827593
Name:PHYSICIANS CLINIC OF SPOKANE
Entity Type:Organization
Organization Name:PHYSICIANS CLINIC OF SPOKANE
Other - Org Name:PCOS INDEPENDENT LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-353-3973
Mailing Address - Street 1:820 S. MCCLELLAN #LL10
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204
Mailing Address - Country:US
Mailing Address - Phone:509-353-3973
Mailing Address - Fax:509-838-8275
Practice Address - Street 1:820 S. MCCLELLAN #LL10
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204
Practice Address - Country:US
Practice Address - Phone:509-353-3973
Practice Address - Fax:509-838-8275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAL0620049291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA137415OtherL&I
WA7102148Medicaid
WAAB11589Medicare ID - Type Unspecified