Provider Demographics
NPI:1265845713
Name:NORTHWEST SPINE SURGERY, LLC
Entity Type:Organization
Organization Name:NORTHWEST SPINE SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-834-7050
Mailing Address - Street 1:1110 N. 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-1622
Mailing Address - Country:US
Mailing Address - Phone:509-834-7050
Mailing Address - Fax:509-834-7051
Practice Address - Street 1:1110 N. 35TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1622
Practice Address - Country:US
Practice Address - Phone:509-834-7050
Practice Address - Fax:509-834-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603404908174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty