Provider Demographics
NPI:1811726193
Name:WASHINGTON STATE UNIVERSITY
Entity type:Organization
Organization Name:WASHINGTON STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOCARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-505-7481
Mailing Address - Street 1:412 E SPOKANE FALLS BLVD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-2131
Mailing Address - Country:US
Mailing Address - Phone:509-505-7481
Mailing Address - Fax:509-606-2515
Practice Address - Street 1:310 N RIVERPOINT BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1610
Practice Address - Country:US
Practice Address - Phone:509-505-7481
Practice Address - Fax:509-606-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-26
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty