Provider Demographics
NPI:1548229255
Name:INLAND NORTHWEST ORTHOTICS AND PROSTHETICS, INC
Entity Type:Organization
Organization Name:INLAND NORTHWEST ORTHOTICS AND PROSTHETICS, INC
Other - Org Name:THOMPSON CUSTOM ORTHOTIC & PROSTHETIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:DELEGATED OFFICIAL
Authorized Official - Phone:509-624-1308
Mailing Address - Street 1:401 S SHERMN ST.
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-6001
Mailing Address - Country:US
Mailing Address - Phone:509-624-1308
Mailing Address - Fax:509-624-5537
Practice Address - Street 1:8920 N HESS ST
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9183
Practice Address - Country:US
Practice Address - Phone:208-719-9221
Practice Address - Fax:509-624-5537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602056141335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9050030Medicaid
WA9050030Medicaid