1245214543 NPI number — JERRY M JOHNSON ETAL PTR FOUR SEASONS PHYSICAL THERAPY

Table of content: (NPI 1245214543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245214543 NPI number — JERRY M JOHNSON ETAL PTR FOUR SEASONS PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERRY M JOHNSON ETAL PTR FOUR SEASONS PHYSICAL THERAPY
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:
6
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:
1245214543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 W WELLESLEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99205-1274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-327-1578
Provider Business Mailing Address Fax Number:
509-327-1596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 W WELLESLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99205-1274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-327-1578
Provider Business Practice Location Address Fax Number:
509-327-1596
Provider Enumeration Date:
12/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
509-327-1578

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  601871376 , 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: 7116312 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com