Provider Demographics
NPI:1720247877
Name:VANCOUVER SPINE & ORTHOPEDIC REHABILITION CENTER, PLLC
Entity Type:Organization
Organization Name:VANCOUVER SPINE & ORTHOPEDIC REHABILITION CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-253-6883
Mailing Address - Street 1:11802 NE 65TH ST # 100
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-5521
Mailing Address - Country:US
Mailing Address - Phone:360-253-6883
Mailing Address - Fax:
Practice Address - Street 1:11802 NE 65TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-5521
Practice Address - Country:US
Practice Address - Phone:360-253-6883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002774174400000X
WAPT00006628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty