Provider Demographics
NPI:1528391810
Name:NORTHWEST SPORTS AND SPINE
Entity Type:Organization
Organization Name:NORTHWEST SPORTS AND SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-624-9112
Mailing Address - Street 1:105 W 8TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2302
Mailing Address - Country:US
Mailing Address - Phone:509-624-9112
Mailing Address - Fax:509-624-1087
Practice Address - Street 1:105 W 8TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2302
Practice Address - Country:US
Practice Address - Phone:509-624-9112
Practice Address - Fax:509-624-1087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000422502081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty