Basic Information
Provider Information | |||||||||
NPI: | 1326539834 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST PAIN SPECIALISTS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2589 | ||||||||
Address2: |   | ||||||||
City: | IDAHO FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 834032589 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2085252090 | ||||||||
FaxNumber: | 2085238978 | ||||||||
Practice Location | |||||||||
Address1: | 8819 W VICTORIA AVE | ||||||||
Address2: |   | ||||||||
City: | KENNEWICK | ||||||||
State: | WA | ||||||||
PostalCode: | 99336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094605500 | ||||||||
FaxNumber: | 5094605111 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2018 | ||||||||
LastUpdateDate: | 05/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEGG | ||||||||
AuthorizedOfficialFirstName: | RUSSELL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6146255805 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 60674447 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.