Provider Demographics
NPI:1013608801
Name:14114 SPOKANE DETOX LLC
Entity Type:Organization
Organization Name:14114 SPOKANE DETOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROTKEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-222-1719
Mailing Address - Street 1:1701 GREEN RD STE C
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-1074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14114 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2102
Practice Address - Country:US
Practice Address - Phone:561-222-1719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility