1588774491 NPI number — SEQUIM PHYSICAL THERAPY CENTER, PS

Table of content: (NPI 1588774491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588774491 NPI number — SEQUIM PHYSICAL THERAPY CENTER, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEQUIM PHYSICAL THERAPY CENTER, PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FYZICAL THERAPY AND BALANCE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588774491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 W FIR ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
SEQUIM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98382-3201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-683-0632
Provider Business Mailing Address Fax Number:
360-681-5483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W FIR ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SEQUIM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98382-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-683-0632
Provider Business Practice Location Address Fax Number:
360-681-5483
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILWERT
Authorized Official First Name:
JASON
Authorized Official Middle Name:
S
Authorized Official Title or Position:
BUSINESS OWNER
Authorized Official Telephone Number:
360-683-0632

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  6022916710010001 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7117260 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0173768 . This is a "WORKMANS COMP DEPT OF L&I" identifier . This identifiers is of the category "OTHER".




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