Provider Demographics
NPI:1689032096
Name:TRI PAIN MANAGEMENT & SPORTS REHABILITATION
Entity Type:Organization
Organization Name:TRI PAIN MANAGEMENT & SPORTS REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:IMPECOVEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:509-218-9520
Mailing Address - Street 1:10912 E 5TH CT
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-2851
Mailing Address - Country:US
Mailing Address - Phone:509-218-9520
Mailing Address - Fax:509-838-1780
Practice Address - Street 1:3324 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-2619
Practice Address - Country:US
Practice Address - Phone:509-218-9520
Practice Address - Fax:509-838-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-01
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60446352225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty