1053356717 NPI number — PACIFIC REHABILITATION & SPORTS MEDICINE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053356717 NPI number — PACIFIC REHABILITATION & SPORTS MEDICINE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC REHABILITATION & SPORTS MEDICINE INC
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:
1053356717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
01/08/2008
NPI Reactivation Date:
02/29/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4716 OLD GETTYSBURG RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MECHANICSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-975-4503
Provider Business Mailing Address Fax Number:
717-975-9781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17910 TALBOT RD S
Provider Second Line Business Practice Location Address:
#101
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-235-5588
Provider Business Practice Location Address Fax Number:
425-687-9410
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TARVIN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
717-975-4503

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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