1306947841 NPI number — SOUTH WHIDBEY PHYSICAL THERAPY AND SPORTS CLINIC INC

Table of content: (NPI 1306947841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306947841 NPI number — SOUTH WHIDBEY PHYSICAL THERAPY AND SPORTS CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH WHIDBEY PHYSICAL THERAPY AND SPORTS CLINIC INC
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:
1306947841
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 643
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98236-0643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-341-1299
Provider Business Mailing Address Fax Number:
360-341-1277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11042 SR 525 # 134
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98236-8618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-341-1299
Provider Business Practice Location Address Fax Number:
360-341-1277
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOETZ
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
360-341-1299

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  601918262 , 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: 0181085 . This is a "DEPT OF LABOR AND INDUSTR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7092463 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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