Provider Demographics
NPI:1982058814
Name:NW INTERVENTIONAL MEDICINE AND ORTHOPEDIC REHAB PLLC
Entity Type:Organization
Organization Name:NW INTERVENTIONAL MEDICINE AND ORTHOPEDIC REHAB PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-253-6883
Mailing Address - Street 1:11802 NE 65TH ST.
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662
Mailing Address - Country:US
Mailing Address - Phone:360-253-6883
Mailing Address - Fax:360-892-7040
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
Practice Address - Country:US
Practice Address - Phone:360-253-6883
Practice Address - Fax:360-892-7040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty