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

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 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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