Provider Demographics
NPI:1568701811
Name:BONNIE PETERSON
Entity Type:Organization
Organization Name:BONNIE PETERSON
Other - Org Name:ON BROADWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-413-2790
Mailing Address - Street 1:915 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2119
Mailing Address - Country:US
Mailing Address - Phone:509-413-2790
Mailing Address - Fax:509-315-8354
Practice Address - Street 1:3120 S GRAND BLVD UNIT 8473
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-2681
Practice Address - Country:US
Practice Address - Phone:509-315-5561
Practice Address - Fax:509-315-8354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60112430225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty