1477574606 NPI number — WALLA WALLA PHYSICAL THERAPY CENTER APS

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 1477574606 NPI number — WALLA WALLA PHYSICAL THERAPY CENTER APS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLA WALLA PHYSICAL THERAPY CENTER APS
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:
1477574606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/02/2023
NPI Reactivation Date:
06/22/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 W TIETAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362-4363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-522-0114
Provider Business Mailing Address Fax Number:
509-522-9868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W TIETAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-4363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-522-0114
Provider Business Practice Location Address Fax Number:
509-522-9868
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PHYSICAL THERAPIST/OWNER
Authorized Official Telephone Number:
509-522-0114

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  601 755 670 , 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: 1306849955 . This is a "NPI MICHAEL J CLARK PT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 650011919 . This is a "RAILROAD MEDICARE MIKE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8861197 . This is a "MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8348476 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD4682 . This is a "RAILROAD MED GROUP #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7082266 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8462996 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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