1326048364 NPI number — RENTON SPORTS & SPINE PT

Table of content: (NPI 1326048364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326048364 NPI number — RENTON SPORTS & SPINE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENTON SPORTS & SPINE PT
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:
RENTON SPORTS & SPINE PT
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:
1326048364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19400 108TH AVE SE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
KENT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98031-0108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-917-9885
Provider Business Mailing Address Fax Number:
253-277-0737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19400 108TH AVE SE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
KENT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98031-0108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-917-9885
Provider Business Practice Location Address Fax Number:
253-277-0737
Provider Enumeration Date:
07/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICAL THERAPIST/CLINCI DIRECTOR
Authorized Official Telephone Number:
425-917-9885

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00002862 , 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: 7293608 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8351397 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 650021468 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 147035 . This is a "DEPT OF VTT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4465984 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5324J0 . This is a "REGENCE BS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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