Provider Demographics
NPI:1356667026
Name:MOBILE ANESTHESIA FOR CHILDREN
Entity Type:Organization
Organization Name:MOBILE ANESTHESIA FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BOTTORFF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-990-5821
Mailing Address - Street 1:9302 N COLTON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1290
Mailing Address - Country:US
Mailing Address - Phone:509-863-9460
Mailing Address - Fax:509-868-0428
Practice Address - Street 1:9302 N COLTON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1290
Practice Address - Country:US
Practice Address - Phone:509-863-9460
Practice Address - Fax:509-868-0428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009793261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental