1558509786 NPI number — BONNEY LAKE PHYSICAL THERAPY AND HAND REHAB, PLLC

Table of content: (NPI 1558509786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558509786 NPI number — BONNEY LAKE PHYSICAL THERAPY AND HAND REHAB, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BONNEY LAKE PHYSICAL THERAPY AND HAND REHAB, 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:
1558509786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20910 STATE ROUTE 410 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNEY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98391-6302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-862-2575
Provider Business Mailing Address Fax Number:
253-862-2675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20910 STATE ROUTE 410 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391-6302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-862-2575
Provider Business Practice Location Address Fax Number:
253-862-2675
Provider Enumeration Date:
01/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EGBERT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
253-862-2575

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  PT5418 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X , with the licence number: OT2499 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XP0019X , with the licence number: OT2499 , 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: PT5418 , 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: 246114 . This is a "LABOR AND INDUSTRIES PT/ MICHAEL" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7421EG . This is a "BLUE SHIELD MICHAEL PT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8879641 . This is a "MEDICARE PTAN BRANDY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 246111 . This is a "LABOR AND INDUSTRIES OT/ BRANDY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 264113 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 6598CA . This is a "BLUE SHILD BRANDY OT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7146897 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G8879917 . This is a "INDIVIDUAL PTAN MICHCAEL" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8368854 . This is a "MEDICAID OCCUPATIONAL THERAPY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8543712 . This is a "MEDICAID PHYSICAL THERAPY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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