Provider Demographics
NPI:1336646694
Name:SPOKANE WELLNESS CENTER
Entity Type:Organization
Organization Name:SPOKANE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HILLIARD-LYTHGOE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:509-904-1644
Mailing Address - Street 1:3324 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-2619
Mailing Address - Country:US
Mailing Address - Phone:509-904-1644
Mailing Address - Fax:509-904-1676
Practice Address - Street 1:3324 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-2619
Practice Address - Country:US
Practice Address - Phone:509-904-1644
Practice Address - Fax:509-904-1676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1376984682Medicaid