1518176650 NPI number — GRAVELLY LAKE PHYSICAL THERAPY, 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 1518176650 NPI number — GRAVELLY LAKE PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAVELLY LAKE PHYSICAL THERAPY, 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:
1518176650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 65368
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNIVERSITY PLACE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98464-1368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-588-2880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3130 SYLVAN DR W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-2514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-588-2880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURKHART
Authorized Official First Name:
LAURIE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
253-588-2880

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , 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)





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