1679698518 NPI number — NW SPORTS REHAB, CORP.

Table of content: (NPI 1679698518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679698518 NPI number — NW SPORTS REHAB, CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NW SPORTS REHAB, CORP.
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:
NW SPORTS REHAB
Provider Other Organization Name Type Code:
3
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:
1679698518
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33400 13TH PL S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98003-6357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-838-6070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33400 13TH PL S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-6357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-838-6070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SU-BROWN
Authorized Official First Name:
MING MING
Authorized Official Middle Name:
AUDREY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
253-838-6070

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 171100000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225700000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DD7854 . This is a "GROUP RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 158881 . This is a "GROUP L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".