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Alva Jack Childress
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NPI Number Detailed Information
Provider Information:
| Name: | Alva Jack Childress |
| Gender: | M |
| Provider License Number If Given: | MD60096557 |
NPI Information:
| NPI: | 1467451906 |
| Entity Type (Individual or Organization): |
1-ind |
| Enumeration Date: | 7/18/2005 |
| Last Update Date: | 10/21/2015 |
Provider Business Mailing Address:
| Address: | PO BOX 421 Liberty Lake, WA 99019 |
| Phone Number: | 8667472455 |
| Fax Number: |
Provider Business Practice Location Address:
| Address: | 101 W 8TH AVE SUITE 1100 Spokane, WA 99204 |
| Phone Number: | 5094744060 |
| Fax Number: | 5094746198 |
Provider Taxonomy:
| Primary: | 207V00000X |
| Secondary (if any): | 207V00000X |
| State: | WA |
