Provider Demographics
NPI:1063925816
Name:MAYGREN, BOWEN
Entity type:Individual
Prefix:
First Name:BOWEN
Middle Name:
Last Name:MAYGREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 W LAPWAI AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-0086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15312 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-5109
Practice Address - Country:US
Practice Address - Phone:509-202-9384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist