Provider Demographics
NPI:1558048280
Name:LIBERTY LAKE DIRECT PRIMARY CARE PLLC
Entity Type:Organization
Organization Name:LIBERTY LAKE DIRECT PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:W
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-828-5250
Mailing Address - Street 1:704 N MADSON CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7507
Mailing Address - Country:US
Mailing Address - Phone:509-828-5250
Mailing Address - Fax:
Practice Address - Street 1:2207 N MOLTER RD
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7570
Practice Address - Country:US
Practice Address - Phone:509-348-2214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty