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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

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