1548217631 NPI number — SOUTH SOUND PHYSICAL & HAND THERAPY PLLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548217631 NPI number — SOUTH SOUND PHYSICAL & HAND THERAPY PLLC

Employer Identification Number (EIN):

Provider Organization Name:

SOUTH SOUND PHYSICAL & HAND 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 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:

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Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1548217631

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

06/15/2015

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

4220 132ND ST SE

Provider Second Line Business Mailing Address:

SUITE 101

Provider Business Mailing Address City Name:

MILL CREEK

Provider Business Mailing Address State Name:

WA

Provider Business Mailing Address Postal Code:

98012-8999

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

425-357-9380

Provider Business Mailing Address Fax Number:

425-357-9382

Provider First Line Business Practice Location Address:

111 MARKET ST NE

Provider Second Line Business Practice Location Address:

SUITE 108

Provider Business Practice Location Address City Name:

OLYMPIA

Provider Business Practice Location Address State Name:

WA

Provider Business Practice Location Address Postal Code:

98501-1008

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

360-754-7085

Provider Business Practice Location Address Fax Number:

360-754-3671

Provider Enumeration Date:

05/27/2006

Authorized Official Last Name:

O'KELLEY

Authorized Official First Name:

MICHAEL

Authorized Official Middle Name:

SHANNON

Authorized Official Title or Position:

PRESIDENT/OWNER

Authorized Official Telephone Number:

425-316-8046

• Taxonomy code: 225700000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 225XH1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0164914 . This is a "DEPT. OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0164914 . This is a "L&I CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: DA0695 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 3583413-00 . This is a "OWCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 7108MA . This is a "REGENCE BLUESHIELD GRP #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 9054982 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
• Identifier: 7683600 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
• Identifier: 7112980 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".