Provider Demographics
NPI:1740328145
Name:ABSTEMIOUS OUTPATIENT CLINIC, INC
Entity type:Organization
Organization Name:ABSTEMIOUS OUTPATIENT CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR ABSTEMIOUS OUTPA
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:BA, CDP
Authorized Official - Phone:509-927-7814
Mailing Address - Street 1:10525 E. MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-3728
Mailing Address - Country:US
Mailing Address - Phone:509-927-7814
Mailing Address - Fax:509-927-4669
Practice Address - Street 1:10525 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-3728
Practice Address - Country:US
Practice Address - Phone:509-927-7814
Practice Address - Fax:509-927-4669
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABSTEMIOUS OUTPATIENT CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-01
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA32051201261QR0405X
WACP0001358261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA32051200OtherDSHS
WA32051200OtherDASA
WA32051201OtherDASA
WA32051200/32051201OtherDSHS/DBHR
WA32051201OtherDSHS