Provider Demographics
NPI:1023366812
Name:COPPER CREEK MEDICAL, INC.
Entity Type:Organization
Organization Name:COPPER CREEK MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:TALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-998-4309
Mailing Address - Street 1:21222 30TH DR SE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-7019
Mailing Address - Country:US
Mailing Address - Phone:206-621-1982
Mailing Address - Fax:425-820-0831
Practice Address - Street 1:3410 E DESMET AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-4514
Practice Address - Country:US
Practice Address - Phone:509-536-7626
Practice Address - Fax:509-536-7629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies