1649353053 NPI number — EAGLE ROCK PHYSICAL THERAPY PLLC

Table of content: (NPI 1649353053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649353053 NPI number — EAGLE ROCK PHYSICAL THERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE ROCK PHYSICAL THERAPY PLLC
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:
Provider Other Organization Name Type Code:
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:
1649353053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 769
Provider Second Line Business Mailing Address:
411 HOSPITAL WAY
Provider Business Mailing Address City Name:
BREWSTER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-689-4301
Provider Business Mailing Address Fax Number:
509-689-4307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREWSTER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-689-4301
Provider Business Practice Location Address Fax Number:
509-689-4307
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SONNEMAN
Authorized Official First Name:
LISA
Authorized Official Middle Name:
DIANE
Authorized Official Title or Position:
CO OWNER AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
509-689-4301

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00006129 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT00003294 , 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: 8323479 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8374126 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0206563 . This is a "L & I BRIAN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0206566 . This is a "L & I USR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8374126 . This is a "UNITED MEDICAL" identifier . This identifiers is of the category "OTHER".




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