Provider Demographics
NPI:1619122603
Name:MACOMBER, MICHAEL GLEN (CHT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GLEN
Last Name:MACOMBER
Suffix:
Gender:M
Credentials:CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 N MORTON ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-2586
Mailing Address - Country:US
Mailing Address - Phone:509-270-0957
Mailing Address - Fax:
Practice Address - Street 1:1811 N MORTON ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-2586
Practice Address - Country:US
Practice Address - Phone:509-270-0957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA10001683174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist