Provider Demographics
NPI:1659627974
Name:FORTY SIX & TWO, LLC
Entity Type:Organization
Organization Name:FORTY SIX & TWO, LLC
Other - Org Name:INDIAN TRAIL PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:509-979-5981
Mailing Address - Street 1:8801 N INDIAN TRAIL RD STE I
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-6052
Mailing Address - Country:US
Mailing Address - Phone:509-465-4799
Mailing Address - Fax:
Practice Address - Street 1:8801 N INDIAN TRAIL RD STE I
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6052
Practice Address - Country:US
Practice Address - Phone:509-465-4799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008588261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy